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CONTRIBUTIONS  TO  THE  STUDY 


OF 


DISEASES 


OF  THE 


Heart  and  Lungs 


BY 


JAMES  R.  LEAMING,  M.D., 

Professor  of  Diseases  of  the  Chest  and  Physical  Diagnosis  in  the  New  York 

Polyclinic;    Special  Consulting  Physician   in    Chest  Diseases, 

St.  Luke's  Hospital,  A^ew  York,  Etc. 


BERMINGHAM  &  COMPANY, 


28  Union  Square,  East, 
NEW  YORK. 


20  King  William  Street,  Strand, 
LONDON. 


1884. 


Copyright,  1884,  by  Bermingham  &  Co. 


To  THE  Memory 

OF 

GEORGE   PHILIP   CAMMANN, 


OF   NEW   YORK. 


A    PUPIL    OF    LOUIS,    AND    ONE    OF    THE    EARLIER    AUSCULIATORS    OF    THIS 

COUNTRY,    AND    MY     TEACHER,     THESE    MONOGRAPHS 

ARE    REVERENTLY   DEDICATED. 

J.  R.  L. 


L-4-1 


CONTENTS. 


PAGE 

Introduction 5 

I.   Remarks  made  before  the  New  York  Academy  of  Medicine, 

in  Discussing  Dr.  Alonzo  Clark's  Paper  on  Pneumonia. ...  17 

II.   Pleuritis ,  24 

III.  Respiratory  Murmurs 32 

IV.  Plastic  Exudation  within  the  Pleura 54 

V.   Physical  Signs  of  Interpleural  Pathological  Processes 71 

VI.   On  Haemoptysis 97 

VII.   Endemic  Pleuro-Pneumonia  as  Seen  in  New  York  during  the 

Past  Ten  or  Twelve  Years 114 

VIII.   Cardiac  Murmurs 132 

IX.   Significance  of  Disturbed  Action  and  Functional  Murmurs  of 

the  Heart 165 

X.   A  New  Classification  of  Phthisis  Pulmonalis,  with  Reference 

to  Special  Treatment 193 

XI.   Therapeutics  of  Chloride  of  Ammonium 221 

XII.   Is  Consumption  Communicable? 243 

XIII.  Bronchitis *. 253 

XIV.  Chronic  Pleurisy 260 

XV.   Therapeusis  of  Mercury 266 

XVI.  Thuja  Occidentalis............ ........,.,.,.  271 


INTRODUCTION. 


These  monographs  which  from  time  to  time  have 
appeared  in  the  medical  journals  are  here  collected, 
and  the  dates  of  their  publication  given,  at  the  request 
of  very  many  medical  friends  in  widely  different  parts 
of  the  country.  This  publication  by  no  means  aspires 
to  the  dignity  of  a  systematic  treatise,  but  embodies 
some  new  views  of  a  revolutionary  character,  which 
may  be  of  some  practical  use  to  the  profession. 

All  that  is  new  in  them  of  physical  signs  in  diag- 
nosis of  pathological  processes  connected  with  the 
organs  of  respiration,  had  its  origin  in  the  discovery  of 
true  respiratory  murmur,  its  cause  and  site  in  1859-60. 

It  is  true  that  bronchial  respiration  and  pulmonary 
respiration  are  terms  which  were  used  by  Laennec. 
They  more  correctly  describe  the  site  of  their  origin 
than  the  term  substituted  by  Andral,  vesicular  mur- 
mur. At  that  time  the  existence  and  active  quality 
of  residual  air  was  but  little  known.  Laennec  taught, 
as  did  his  followers,  that  the  cause  of  respiratory  mur- 
murs was  friction  of  air  in  motion,  meeting  resistance 
m  its  course  in  the  air  passages  and  in  the  air  cells. 
That  the  air  moved  into  the  vesicles  or  cells  and  out 
again,  as  it  did.  through  the  bronchasa,  and  that  the 
friction  resulting  from  the  anatomical  peculiarities  of  in- 
fundibulum,  and  cell  was  the  cause  of  the  breezy  soft  ex- 


6  *  INTRODUCTION. 

panding  murmur  so  characteristic  of  the  respiratory  act 
in  health.  There  has  since  been  no  successful  attempt  to 
analyze  bronchial  respiration  and  pulmonary  respiration 
more  than  had  been  done  by  Laennec.  Even  the 
acute  and  acomplished  Hyde  Salter,  who  fully  re- 
cognized the  existence  and  special  qualities  of  residual 
air,  still  could  not  rid  himself  of  the  idea  that« vesicular 
murmur  resulted  as  did  the  bronchial  from  friction.  It 
seems  incredible  in  the  light  of  direct  experiment  that 
a  view  so  erroneous  could  so  long  have  been  maintained 
without  serious  question.  If  we  take  an  india-rubber 
bag  with  a  long  neck  and  a  hard  rubber  nozzle  and  stop- 
cock, and  fill  it  full  with  air  it  will  represent  an  air- 
sac  bronchioli,  and  bronchus  after  respiration.  What 
remains  in  the  bag  is  the  residual  air.  If  one  tenth 
part  more  of  its  contents  should  be  added  by  blowing 
into  the  nozzle  it  will  distend  the  bag  just  so  much 
more — one  tenth  part.  Now  in  this  act  of  filling  the  bag 
by  blowing  into  the  nozzle  there  is  air  and  tube  friction 
at  the  hard  rubber  orifice  ;  but  there  is  none  in  the 
distensible  tube  and  bag  which  represent  the  distensible 
bronchioli  and  airrsacs.  Being  distensible  they  fill  and 
expand,  there  is  no  friction  against  the  walls,  for  the 
active  contraction  of  the  sac  compresses  the  residual  air 
and  prevents  all  motion  except  the  molecular,  which  is 
without  friction.  In  order  to  cause  friction  in  a  shut 
sac  or  bag  it  would  be  necessary  that  there  should  be 
two  convective  tubes  for  each  bag,  one  to  convey  the 
air  into  the  bag  and  one  to  pass  it  out.  A  double  can- 
nular  arrangement,  like  an  instrument  for  irrigating  the 
bladder.  In  the  bronchioli  and  air-sacs  are  developed 
alveoli  for  the  distribution  of  the  capillaries  of  the  pul- 
monary artery,  containing  venous  blood  for  aeration. 
This  comprises  all  of  the  true  respiratory  system.  It  is 
formed  of  white  and  yellow  fibrous  tissue,  with  muS' 


INTRODUCTION.  7 

cular  fibers  and  blood  vessels.  It  is  of  great  tenuity, 
and  the  capillaries  are  thus  brought  in  contact  with  the 
oxygen  of  the  residual  air,  and  under  the  influence  of 
the  law  of  affinitive  attraction.  Each  blood  globule  is 
drawn  through  the  capillaries  and  runs  onward  until 
it  meets  its  particle  of  air  and  makes  exchange  of  tissue 
detritus  for  oxygen.  Thus  is  constant  movement  in  the 
capillaries  insured  as  well  as  molecular  attraction  and 
repulsion  of  air  particles. 

In  all  of  this  complex  mechanism  the  residual  air  is 
constantly  kept  freshened  by  additions  at  each  inspira- 
tion, these  additions  expand  the  contracting  sac,  and 
the  rarefaction  of  the  newly  inspired  air  for  a  short 
time  continues  to  increase  the  expansion.  The  living 
muscular  fibers  enclosing  the  residual  air  contract  upon 
it,  and  compress  it,  forming  a  resonator  of  wonderful 
delicacy  and  power.  All  of  the  frictions  in  the  upper 
passages  are  resonated  in  this  sac  of  compressed  resi- 
dual air,  and  the  muscular  sussurrurs  of  the  contract- 
ing sac  is  also  consonated  with  great  distinctness.  There 
are  millions  of  these  sacs  throughout  the  true  respira- 
tory system,  and  being  pressed  together  and  against  the 
chest  wall  they  acquire  the  function  of  sound  transmis- 
sion. The  consonated  vibrations  from  the  upper  bron- 
chial as  well  as  of  the  muscular  vibrations  of  the  con- 
tracting sacs  are  thus  brought  to  the  ear  through  the 
chest  wall.  These  are  the  respiratory  murmurs.  The 
broncho-respiratory  and  the  true  respiratory  united. 
In  ordinary  respiration  they  have  not  heretofore  been 
distinguished  as  separate  and  different.  In  fact  the 
friction  sounds  of  the  broncho-respiratory  murmur  have 
ever  been  described  as  vesicular. 

Laennec  directs  the  beginner  in  auscultation  to  desire 
the  patient  to  breathe  quickly  in  order  to  increase  the  res- 
piratory sound.     "  The  sound  is  more  distinct  in  proper- 


8  INTRODUCTION. 

tion  as  the  respiration  is  more  frequent.  A  very  deep 
inspiration  made  very  slowly,  will  sometimes  be  scarcely 
audible."  Here  he  undoubtedly  refers  to  tidal  air  fric- 
tion murmur,  and  does  not  recognize  the  true  respiratory. 
He  speaks  of  the  difference  in  the  respiration  in  children 
from  that  of  adults.  *^  It  appears,  as  if  in  children,  we  could 
distinctly  hear  the  dilatation  of  the  air  cells  to  their  full 
extent ;  whilst,  in  adults,  these  seem  as  if,  from  their 
stiffness,  they  could  only  hear  a  partial  dilatation."  He 
says,  ''  Some  few  individuals,  again,  preserve  through  life 
a  state  of  respiration  resembling  that  of  children,  and 
which  I  shall  therefore  denominate  puerile^  in  whatever 
age  it  may  be  perceptible.  "  We  see  by  these  quotations 
that  he  considered  friction  sounds  as  of  pulmonary  respira- 
tion, while  at  the  same  time  he  unconsciously  recognized 
the  absence  of  true  respiratory  murmur.  For  in  children 
the  true  respiratory  is  always  absent,  because  the  true 
respiratory  system  does  not  begin  to  develope  into  full- 
ness of  function  until  after  eight  years,  and  is  not  full 
until  after  sixteen.  Consequently  puerile  respiration  ap- 
plied to  adults  can  only  be  used  as  a  sign  of  disease. 

Soon  after  receiving  the  appointment  of  physician  for 
diseases  of  the  chest  in  Demilt  Dispensary  in  1859,  ^ 
patient  appeared  for  examination,  in  which  the  breath 
sounds  were  not  loud.  I  desired  him  to  hurry  the  res- 
piration, as  directed  by  Laennec,  in  order  to  make  them 
more  distinct.  There  was  a  constant  humming  sound 
of  low  pitch  in  his  chest  that  seemed  to  obscure  the 
breath-sounds.  I  made  his  case  my  particular  study,  and 
I  found  that  this  resonant  humming  sound,  although 
continuous,  was  increased  and  decreased  in  fullness  by 
inspiration  and  expiration  and  was  full,  when  he  held  his 
breath  after  a  deep  inspiration,  when  it  could  be  heard 
alone  without  accompanying  breath  sounds.  After  care- 
ful investigations  I  became  convinced  that  his  chest  was 


INTRODUCTION.  9 

exceptionally  healthy  in  all  its  conditions,  and  that  this 
murmur  was  an  evidence  of  its  perfect  condition.     I  ap- 
plied  the   test   of  this  murmur  to    other   patients   and 
found  that  in  every  instance  it  measured  the  capacity  of 
the   lungs  for  aeration  of  the  blood.      That  when    this 
murmur  was    feeble    or   absent  the  breath-sounds  were 
harsh  and  of  raised  pitch,  and  hurried  in  frequency.     Be- 
coming satisfied  that  it  belonged  wholly  to  the  true  res- 
piratory system  and  characterized  its  functional  capacity, 
I  called  it  the  true  respiratory  murmur  and  the  breath- 
sounds — the    tidal    air    friction-sounds — broncho-respira- 
tory murmurs,  for  both  terms  are  descriptive  of  site  and 
cause.     The  first  public  announcement  of  this  discovery 
was  made  before  the  New  York  Academy  of  Medicine  in 
a  discussion  of  a  paper  on  pneumonia  by  Prof.  A.  Clark, 
in  1865,  and  was  printed  in  the  minutes.     Following  this, 
as   a   matter  of   course,  came    the    conviction    that   the 
adventitious  rales  and  rhonchi  could  not  be  inter-bronchial 
or  interpulmonary  in  their   origin.      But  as  this  knowl- 
edge had   first  to   overcome  preconceived    opinions   my 
progress  was  slow.     The  saddle-leather-creaking  rhonchi 
were  considered  by  the  earlier  auscultators  as  interpleural, 
but   exceptional.     My  daily   experience    at   the    Demilt 
Dispensary  taught  me  that   so-called    dry   sub-crepitant 
rales  were  also  always  interpleural.     But  in  1868  a  case 
occurred  in  St.  Luke's  Hospital  in  which  there  were  liquid 
gurgling  rales  over  one  lung,  which  I  considered  to  be 
evidence  of  small  tubercular  cavities  or  cavernules,  and  so 
explained  them  to  the  house  staff.     At  the  autopsy  it 
was  found  that  the  lung  was  not  diseased,  but  that  there 
were  extensive  cellular  interpleural  adhesions  containing 
fluid. 

The  truth  dawned  upon  me  that  I  had  made  the  same 
mistake  many  times  before.  Since  then  I  have  several 
times    been    able   to   verify   a  diagnosis  of    interpleural 


10  INTRODUCTION. 

pathology  by  similar  physical  signs.  But  it  was  still 
longer  before  I  could  give  up  the  philosophy  of  the  inter- 
pulmonary  site  of  crepitant  rale.  Stubborn  facts  obliged 
me  to  do  so.  I  found  cases  of  centric  pneumonia  with- 
out crepitant  rale,  and  sometimes  cases  of  pleuro-pneu- 
monia  without  crepitant  rale.  I  also  found  cases  of  cre- 
pitant rale  in  firm  interpleural  adhesions  at  the  base  of 
the  lung  without  pneumonia. 

Guided  by  the  correct  philosophy  of  respiratory  mur- 
murs as  given  in  this  paper,  and  applying  to  them  the 
laws  of  sound,  I  awakened  to  the  full  knowledge  of  the 
truth  that  there  can  be  no  adventitious  noises  below  the 
point  of  residual  air,  because  therein  is  no  motion  save 
molecular  movement.  There  is  no  sign  of  pulmonary 
oedema  save  dulness  under  percussion.  It  may  or  it  may 
not  be  accompanied  with  small  moist  rales,  which  have 
been  supposed  to  indicate  it.  They  are  not  always 
present,  and  when  they  are,  they  are  always  of  interpleural 
origin.  They  are  not  physical  signs  of  capillary  bronchitis 
so  frequently  diagnosticated  in  children.  In  fact  the 
disease  itself  does  not  exist  except  as  pneumonitis  from 
which  it  is  not  separable  in  pathology  nor  in  physical 
signs.  Pneumonitis  in  children  is  frequently  unaccom- 
panied with  consolidation  owing  to  the  fact  that  in  chil- 
dren the  true  respiratory  system  is  undeveloped. 

One  other  point  in  the  anatomy  of  the  circulation  of 
the  lungs  of  great  interest,  and  of  late  recognized  by 
anatomists,  has  not  yet  received  that  attention  from 
pathologists  and  diagnosticians  which  its  importance 
demands.  The  nutrient  arteries  of  the  lungs  have  no 
returning  veins,  which  is  an  anomaly  in  the  circula- 
tion of  the  human  body.  All  other  arteries  have  their 
returning  veins,  as  venae  comites,  whether  of  the  sys- 
temic or  pulmonary  circulation.  The  nutrient  artery  of 
the  lungs  is  derived  from  the  bronchial  arteries,  and  is  sys- 


INTRODUCTION.  II 

temic  In  its  origin  and  pulmonic  in  its  end.  Its  blood  after 
performing  its  offices  of  nutrition  of  the  true  respiratory 
system  finds  its  way  into  the  radicles  of  the  pulmonary 
vein,  and  returns  again  to  the  left  heart,  whence  it  came. 
It  arises  from  the  left  heart  and  returns  to  the  left  heart 
always  bearing  arterial  blood.  It  makes  a  short  cut, 
going  but  half  the  usual  round  of  the  circulation.  On  this 
account  there  is  great  sympathy  between  the  bronchaea 
and  the  pulmonary  pleura.  Irritation  of  the  bronchial 
mucous  membrane  may  give  rise  to  interpleural  plastic 
exudation  and  interpleural  plastic  exudation  may  cause 
bronchorrhoea  or  bronchorrhagia.  The  discovery  and 
peculiar  relationship  of  the  nutrient  artery  to  diseases  of 
the  lungs,  pleura  and  bronchial  tubes  is  given  in  the 
article  on  respiratory  murmurs,  published  in  1872. 

The  key  to  diagnosis  of  diseases  of  the  heart  lies  in 
the  solution  of  the  problem  of  the  causes  and  mechanism 
of  the  first  sound.  There  is  no  question  in  regard  to  the 
cause  of  the  second  sound  ;  it  is  merely  the  closure  of  the 
aortic  valve  by  the  return  blood  in  the  aorta  after  the 
heart  ceases  to  contract.  The  heart  is  resting;  the 
column  of  blood  which  it  has  thrown  into  the  aorta  is 
forced  back  by  the  resiliency  of  the  aorta  closing  the 
three-curtained  gate  at  its  entrance  with  a  shock.  The 
intervals  of  silence  are  merely  the  time  of  the  heart's 
rest  divided  by  the  shock  of  the  forced  closure  of  the 
aortic  valve.  All  the  sound  that  the  heart  makes  of 
itself  directly  is  by  its  contraction.  It  has  only  an  indirect 
connection  with  the  second  sound,  the  immediate  cause 
of  which  is  extra  cardiac.  It  has  been  proved  by  experi- 
ment that  the  forcible  closure  of  the  semilunar  valve 
causes  the  second  sound.  The  cause  and  mechanism  of 
the  first  sound  demands  our  special  attention,  for  if 
we  can  demonstrate  this  problem  all  that  is  obscure  or 
a  matter   of   controversy  in  regard   to  the  function  of 


12  INTRODUCTION. 

the  heart's  action,  and  of  the  opening  and  closure  of 
doors  of  exit  and  eiitranee  to  its  chambers  will  have  been 
clearly  understood  and  set  at  rest.  Arriving  at  the  cor- 
rect philosophy  of  the  first  sound  will  enable  us  to  make 
absolute  diagnosis  of  all  the  murmurs  of  the  heart,  organic 
and  functional. 

One  thing  is  certain ;  that  the  first  sound  commences, 
continues,  and  ends  with  the  contraction  of  the  heart. 
The  contraction  of  the  heart  is  the  cause  of  the  first 
sound.  The  heart  contracts  upon  the  blood  contained  in 
the  ventricle,  and  forces  it  into  the  aorta.  And  when 
this  act  is  completed  the  heart  rests,  and  there  is  silence 
only  broken  by  the  closure  of  the  aortic  valve,  the  second 
sound.  The  first  sound  is  the  audible  evidence  of  the 
sole  act  of  the  heart. 

The  consideration  of  this  self-evident  proposition  will 
enable  us  to  form  a  correct  mental  picture  of  the  mechan- 
ism of  the  act.  When  the  first  sound  ceases  there  occurs 
an  interval  of  silence  measured  as  to  its  length  by  the 
second  sound  caused  by  the  forcible  closure  of  the  aortic 
valve,  and  then  follows  the  long  interval  of  silence  which 
elapses  from  the  time  of  the  second  sound  until  the  first 
sound  commences  again. 

By  listening  to  the  first  and  second  sounds,  and  noting 
the  intervals  of  silence  between  them,  we  are  able  to 
judge  of  the  heart's  power  and  its  capacity,  and  whether 
its  valves,  the  doors  which  guard  and  shut  its  entrances 
and  its  exits,  work  in  easy  and  perfect  function,  as 
in  health.  The  first  sound  commences  with  a  low 
note,  gradually  rises  in  pitch,  and  ends  with  the  im- 
pulse beat.  Then  follows  the  short  interval  of  silence, 
then  comes  the  second  sound  which  is  short  and  flat  in 
character,  like  a  smart  blow,  then  follows  the  long  inter- 
val of  silence.  What  is  the  philosophy  of  the  first  sound  ? 
J[t  is  caused  by  contraction  of  the  heart  upon  its  con- 


INTRODUCTION.  1 3 

tained  blood  forcing  the  blood  into  the  aorta,  and  forcing 
the  mitral  valve  into  its  place  and  closing  and  keeping 
closed*  the  auriculo-ventricular  orifice.  The  mitral  valve 
would  be  forced  through  into  the  auricle  by  the  tremen- 
dous effort  of  contraction  were  it  not  for  the  beautiful 
and  admirable  arrangement  of  the  tendinous  cords  which 
hold  the  valve  exactly  in  place.  They  are  attached  to 
the  valve  at  one  end  and  to  the  columnae  carnae  and 
musculi  papillari  and  to  the  walls  of  the  heart  at  the 
other.  When  the  heart  contracts  the  blood  is  forced 
against  the  mitral  valve.  Its  nice  coaptation  is  main- 
tained by  the  chordae  tendinnae  which  are  kept  tense  by 
the  muscular  attachments  so  contrived  that  the  same 
restraint  is  evenly  and  exactly  maintained  until  the  last 
drop  of  blood  is  sent  forcibly  into  the  aorta.  Thus  every 
muscle  in  the  heart  and  every  and  each  muscular  contriv- 
ance of  fleshy  column  and  nipple-like  projection  are  so 
admirably  arranged  that  under  the  influence  of  the  or- 
ganic life  stored  up  in  the  numerous  ganglia  in  and 
about  the  heart — that  every  muscular  fibre  in  whatever 
position  or  place — contracts  just  in  the  right  time  and 
right  place,  and  completes  the  great  effort  of  propulsion 
of  the  blood.  When  this  is  accomplished  suddenly  every 
and  each  fibre  ceases  to  contract,  and  becomes  flaccid 
and  passive,  throughout  the  complex  arrangement.  The 
blood  in  the  venous  system  is  brought  in  by  the  upper 
and  lower  cavse,  and  fills  the  unresisting  heart  with  its 
ounce  of  blood.  The  mitral  valve  is  again  floated  into 
place  when  the  slight  but  lightning-like  movement  of 
the  auricle  gives  the  stimulus  to  the  rested  heart,  and 
instantly  the  contraction  runs  into  the  ventricle,  and 
again  every  fibre  does  its  duty  in  concert  and  successively 
until  another  great  heart  beat  is  accomplished. 

This  wonderfully  complex  arrangement  of  muscle  in  the 
walls  Qf  the  heart  and  in  the  attachments  to  the  chordse 


H 


INTRODUCTION. 


and  mitral  valve  governed  by  the  organic  life,  gives  us 
a  most  remarkable  instrument  for  the  production  of 
sound.  The  chordae  are  musical  strings  which  vibrate  in 
unison  and  are  reproduced  in  the  fibrous  expansion  of  the 
mitral  valve,  which  also  has  its  own  note  of  deep  base. 
When  the  heart  contracts  the  blood  rushes  in  through  and 
among  these  nicely-toned  musical  strings  and  against  the 
mitral  valve  producing  harmonious  vibrations  which  is 
the  first  sound.  So  sensitive  is  each  fibre,  and  in  such 
perfect  concert  is  its  action  with  the  act  of  the  heart,  that 
each  tendinous  cord  is  made  just  so  tense  that  its  vibra- 
tions must  harmonize  with  each  other  cord  and  with  the 
vibrations  of  the  mitral  valve  at  the  same  time,  which  re- 
sults in  the  perfect  harmony  of  the  first  sound. 

The  exactness  and  nicety  of  this  mechanical  arrange- 
ment acting  under  the  organic  life  influence  in  obedience 
to  acoustic  law  gives  us  absolute  power  of  diagnosis.  Any 
variation  from  harmony  in  the  multiple  vibrations  which 
take  place  is  evidence  of  functional  disturbance  or  of  or- 
ganic change.  The  sound  vibration  of  the  chords  ten- 
dinnae  consonated  in  the  mitral  valve  take  place  in  a 
'  closed  chamber,  the  ventricle.  They  are  intraventricular, 
and  are  delivered  in  greatest  intensity  at  the  apex  beat 
in  the  chest  wall.  Any  variation  from  the  normal  heart 
sounds  heard  in  greatest  intensity  at  this  point  are  intra- 
ventricular murmurs. 

Remembering  these  facts  will  enable  us  to  determine 
with  great  precision  the  meaning  of  cardiac  murmurs. 
The  evidence  of  aortic  orifice-disease,  obstruction  and  re- 
gurgitation are  heard  best  over,  or  in  the  immediate  neigh- 
borhood of,  the  semilunar  valve.  The  obstructive  murmur 
may  be  carried  along  with  the  current  of  blood,  but  its 
greatest  intensity  is  over  the  valve.  Aortic  regurgitant 
murmur  is  heard  but  a  short  distance  from  the  aortic  ori- 
fice in  the  direction  of  the  stream  of  blood  forced  back 


INTRODUCTION.  1 5 

into  the  ventricle.  Its  greatest  intensity  may  be  at  about 
half  to  three  quarters  of  an  inch  from  the  aortic  orifice 
either  in  the  sternum  or  in  a  line  from  the  aortic  orifice 
to  the  apex  beat.  It  is  sometimes  conducted  the  length 
of  the  sternum  or  to  the  apex  beat.  The  certain  sign  of 
mitral  regurgitation  is  heard  alone  behind  with  greatest 
intensity  between  the  seventh  and  eighth  vertebrae  to  the 
left  and  near  the  spine.  There  may  be  a  conveyed  sound 
a  short  distance  above  and  below.  This  sign  is  pathogno- 
monic, and  was  first  observed  and  its  diagnostic  value  ex- 
plained by  the  late  Dr.  Geo.  P.  Cammann  of  New  York. 

To  demonstrate  this  discovery  and  its  value  was  the 
object  of  the  first  of  these  papers  on  cardiac  murmurs 
published  in  1868.  The  intelligent  study  of  intraventric- 
ular murmurs  heard  at  the  apex  beat  in  greatest  intensity 
explains  the  true  significance  of  so  called  mitral  regurg- 
itant and  presystolic  or  mitral  direct  murmurs.  They  are 
not  evidence  of  mitral  regurgitation  nor  of  mitral  stenosis 
when  present,  and  are  frequently  absent. 


CONTRIBUTIONS  TO  THE  STUDY 


OF 


DiSEASES  OF  THE  HEART  AND  LUNGS. 


I. 

Remarks  Made  before  the  New  York  Academy 
OF  Medicine,  in  Discussing  Dr.  Alonzo  Clark's 
Paper  on  Pneumonia.* 

Mr.  President  :  In  common  with  many  others,  I 
desire  to  express  my  indebtedness  to  Dr.  Clark  for  the 
knowledge  that  "  the  exudative  matter  in  pneumonia  is 
not  puriform,  and  does  not  become  so  even  in  the  stage 
of  gray  hepatization  ;"  a  knowledge  of  the  highest  prac- 
tical importance,  of  which  I  have  availed  myself  many 
times. 

As  to  the  seat  of  the  inflammatory  action,  and  also  as 
to  the  significance  of  the  physical  sign  of  crepitant  rale, 
I  have  formed  independent  opinions,  not  entirely  in  ac- 
cordance with  those  expressed  by  Dr.  Clark,  nor  with 
those  held  by  the  profession  generally ;  and  1  should 
hesitate  to  advance  them  again-st  such  high  authority, 
did  I  not  believe  that  the  cause  of  truth  may  be  bene- 
fited by  stating  the  reasons  upon  which  they  are  founded. 

I  understand  Dr.  Clark  to  maintain  that  the  seat  of 
disease  in  inflammation  of  the  lungs  is  confined  to  the 
lining   membrane  of   the  air-cells ;    and    the  proof  al- 

*  October,  1865, 


1 8  DISEASES   OF  THE   HEART  AND   LUNGS. 

leged  is  that  in  post-mortem  examinations  the  exuded 
matter  is  always  found  occupying  the  air-cells  alone, 
the  cellular  connective  tissue  being  void  of  pathologi- 
cal change.  This  fact  I  do  not  question,  but  1  do  be- 
lieve that  there  is  a  time  in  the  course  of  the  disease 
when  the  fibrous  connective  tissue  is  the  subject  of  in- 
flammation. The  natural  cure  of  inflammation  is  exu- 
dation ;  but  interstitial  exudation  would  endanger  the 
life  of  this  important  but  delicate  portion  of  the  body ; 
consequently  we  find  the  exuded  matter  poured  into 
the  larger  receptacle  of  the  true  respiratory  system, 
where  it  is  comparatively  innocuous  ;  and  this  is  not  a 
singular  provision,  the  same  thing  is  done  in  inflamma- 
tion of  the  pleura,  for  instance,  when  the  exuded  serum 
is  poured  into  its  cavity.  Ought  we  to  expect  to  find 
interstitial  exudation  as  proof  of  past  inflammation  in 
the  connective  tissue,  when  the  cure  has  already  been 
completed  by  abundant  exudation  into  the  free  and  ca- 
pacious true  respiratory  system  ?  It  seems  to  me  that 
the  fact  of  finding  it  here  is  in  itself  strong  evidence 
that  inflammation  has  previously  existed  in  the  fibrous 
connective  tissue. 

The  air-passages  are  lined  with  ciliated  epithelial 
mucous  membrane,  and  simple  inflammation  of  •this 
membrane  is  not  followed  by  exudation  ;  but  if  the  in- 
flammation extends  to  the  subjacent  tissues,  which  are 
fibrous,  exudation  is  the  natural  result ;  and,  further,  the 
character  of  the  underlying  fibrous  tissue  determines 
the  kind  of  exudation ;  as,  above  the  epiglottis  it  will 
be  diphtherial,  while  below  it  will  be  croupal.  The  mu- 
cous membrane  being  the  same,  the  difference  in  the 
exudation  must  be  owing  to  the  special  conditions  of 
the  underlying  tissues.  If,  then,  the  mucous  mem- 
brane lining  the  larger  air-passages  acts  merely  as  a 
strainer,  and  has  nothing  to  do  with  the  formation  ol 


ON   PNEUMONIA.  I9 

the  exuded  pseudo-membrane,  why  should  the  matter 
exuded  through  the  tessellated  pavement  epithelium  of 
the  true  respiratory  system  be  regarded  as  the  result 
only  of  inflammation  of  that  membrane  ? 

Dr.  Clark  speaks  of  the  sign  of  crepitant  rale  as  de- 
noting the  fact  of  exudation,  and  as  being  caused  by  it. 
To  this  view  I  dissent.  Crepitant  rale  is  a  sign  of  great 
importance  as  marking  one  stage  of  the  disease,  but  not 
that  of  exudation.  The  physical  signs  in  pneumonia  are 
inseparably  connected  with  the  pathological  changes 
which  give  them  existence,  and  during  an  ordinary  at- 
tack of  uncomplicated  pneumonia  their  regular  suc- 
cession is  as  follows :  during  the  stage  of  engorgement 
there  is  muffling  of  the  true  respiratory  sound,  with 
slightly  exaggerated  broncho-respiratory  murmur,  the 
percussion  note  being  a  trifle  raised  in  pitch. 

The  second  change  is  denoted  by  crepitant  rale,  the  dis- 
appearance of  the  true  respiratory  sound,  more  exag- 
geration of  the  broncho-respiratory  murmur,  the  per- 
cussion note  still  further  raised  in  pitch,  but  without 
loss  of  resonance. 

The  third  change  is  marked  by  disappearance  of  crep- 
itus and  the  appearance  of  tubular  breathing  ;  the  per- 
cussion note  is  dull,  flat,  raised  in  pitch,  with  great  loss 
of  resonance.  These  signs  remain  till  resolution  com- 
mences, when  they  gradually  disappear,  and  those  of 
health  take  their  place. 

The  first  change  is  accompanied  by  chilly  sensa- 
tions, pains  in  the  head,  back  and  limbs,  an  acceler- 
ated bounding  pulse,  and  oppressed  respiration.  The 
second  change,  where  crepitus  is  present,  the  breath- 
ing is  hurried  rather  than  oppressed,  the  skin  is  hot 
and  dry,  the  pulse  more  frequent,  harder,  and  smaller, 
and  occasionally  there  is  mental  disturbance.  The 
third  change,  where  the  crepitus  disappears  and  tU' 


20  DISEASES   OF  THE   HEART  AND   LUNGS. 

bular  breathing  takes  its  place,  with  dulness  under 
percussion,  the  activity  of  the  symptoms  notably  sub- 
sides ;  the  respiration,  though  still  frequent,  is  not  so 
hurried  ;  the  pulse  is  softer,  fuller,  and  slower ;  the 
skin  loses  its  heat,  and  sometimes  becomes  moist.  The 
second  change,  where  crepitus  is  present,  I  regard  as 
inflammatory,  with  its  seat  in  the  fibrous  connective  tis- 
sue. The  third  change  indicates  the  natural  cure  by 
exudation.  In  complicated  pneumonia  this  regular  or- 
der ot  signs  and  symptoms  is  interfered  with,  and  some- 
times reversed.  In  broncho-pneumonia  of  the  travelling 
kind,  we  may  have  signs  of  the  process  of  natural  cure 
going  on  in  one  small  portion  of  lung,  while  an  adjacent 
part  may  be  undergoing  the  first  or  second  change.  To 
render  my  views  more  intelligible,  I  will  premise  that 
since  i860  I  have  been  making  respiratory  sounds  a 
subject  of  especial  study.  The  respiratory  murmur, 
or,  as  it  is  sometimes  called,  the  vesicular  murmur,  the 
breath  sound,  has  been  considered,  by  authorities  in  this 
branch  of  our  profession,  as  a  single  element ;  but  this, 
I  think,  is  an  error.  The  respiratory  murmur  is  com- 
posed of  two  elements — the  broncho-respiratory,  formed 
by  the  tidal  air  in  the  convective  tubes,  and  the  true  re- 
spiratory, having  its  origin  alone  in  the  true  respiratory 
system.  They  differ  in  origin,  character,  and  quality, 
and  may  be  studied  separately  as  well  as  in  combination. 
The  lung  is  composed  of  a  convective  system  and  the 
true  respiratory  system.  The  convective  system  is  com- 
posed of  the  bronchial  tubes  and  air-passages,  and  is 
only  shghtly  distensible.  The  true  respiratory  system 
is  composed  of  the  terminal  bronchia,- or  the  air-sacs, 
and  is  characterized  by  the  presence  of  alveoli,  and  is 
immensely  distensible.  These  two  systems  differ  ana- 
tomically, structurally,  and  functionally.  In  unhurried 
healthy  respiration  the  air  enters  in  a  body  into  the 


ON   PNEUMONIA.  ^f 

bronchia  as  far  as  the  third  or  fourth  division,  when  it 
becomes  instantly  mixed  with  the  residual  air,  becom- 
ing- a  component  part  of  it,  and  by  its  addition  equally 
dilating  the  distensible  true  respiratory  system.  These 
physiological  facts  are  pretty  well  established  in  the 
minds  of  competent  observers,  and  being  admitted  pre- 
clude the  idea  of  currents  in  the  residual  air  rushing 
into  air-sacs  and  out  again  through  intralobular  pas- 
sages. 

(can  conceive  of  no  motion  in  the  residual  air  save 
the  molecular,  which  is  governed,  first,  by  the  law  of 
the  diffusion  of  gases,  and,  second,  by  that  of  affinitive 
attraction.  The  newly-introduced  atmospheric  air,  be- 
ing diffused  through  the  residual  air,  now  comes  under 
the  influence  of  the  law  of  affinitive  attraction ;  and 
each  separated  molecule  struggles  toward  the  lining 
membrane  of  an  alveolus  to  meet  a  blood-globule,  which 
is  also  struggling  along  the  network  of  capillaries,  un- 
der the  same  propelling  influence  of  affinitive  attraction, 
gives  up  its  oxygen,  receives  effete  matter  in  exchange, 
loses  its  affinity,  is  repelled,  crowded  back  by  other 
struggling  air  particles,  till  it  is  forced  far  up  in  the 
bronchia,  and  thence  is  expired. 

The  presence  of  muscular  fibre  in  the  delicate  tissues 
of  the.  true  respiratory  system  is  not  yet  established  be- 
yond  all  cavil ;  but  it  is  certain  that  the  air-sacs  have 
power  of  resistance  and  active  contraction,  qualities 
belonging  to  muscle,  of  which  fact  we  are  painfully 
sensible  in  its  loss  in  vesicular  emphysema. 

If  the  ear  be  placed  over  the  lung  of  a  healthy  young 
person  during  unhurried  respiration,  and  the  ausculta- 
tory signs  be  carefully  analyzed,  the  observer  will  be 
conscious  of  two  elementary  sounds  in  the  respiratory 
murmur.  The  broncho-respiratory  or  tidal-air  sound 
will  be  heard  almost  entirely  alone  in  inspiration,  and 


22  DISEASES   OF   THE   HEiART  A^E)   LUNGS. 

will  be  recognized  as  air-friction  sound,  is  of  moderate- 
ly high  pitch  and  slightly  harsh  in  character,  and  has 
been  likened  to  the  gentle  rustling  of  the  leaves  of  a 
tree  stirred  by  the  breeze.  The  other,  which  is  the  true 
respiratory  element,  is  a  soft,  gentle  murmur,  low  in 
pitch,  heard  both  in  inspiration  and  expiration,  swelling 
in  the  one  and  diminishing  in  the  other,  is  continuous, 
and  may  be  compared  to  the  roar  of  the  sea  heard  at  a 
great  distance. 

It  differs  in  pitch  and  quality  from  all  other  respira- 
tory sounds,  and  impresses  the  mind  with  the  idea  of  an 
infinite  number  of  regular  vibrations.  Its  separate  iden- 
tity and  distinctive  qualities  may  be  studied  to  best  ad- 
vantage when  all  other  sounds  are  cut  off  in  the  air- 
passages  by  holding  the  breath.  It  is  not  a  character- 
less, noise,  but  is  a  sound  subject  to  definite  acoustic 
law,  and  its  alteration  or  diminution  is  the  earliest  sign 
we  have  of  approaching  pulmonary  disease.  It  is  not 
readily  heard :  an  acute  ear,  even  after  considerable 
auscultatory  education,  is  necessar}^  to  its  discriminat- 
ing analysis  being  of  the  highest  diagnostic  value.  In 
the  congestive  stage  of  pneumonia  it  is  muffled  and  ob- 
scured, and  when  crepitus  gives  evidence  of  the  second 
change  it  disappears. 

Whatever  may  be  considered  as  the  cause  of  the  true 
respiratory  sound,  it  is  only  coexistent  with  a  healthy  con- 
dition of  the  true  respiratory  system.  At  the  first  in- 
vasion of  inflammation  the  true  respiratory  system  loses 
its  quality  of  distensibility,  and  each  inspiration  after- 
ward, suddenly  increasing  the  volume  of  residual  air, 
forcibly  distends  the  altered  and  stiffened  air-sacs  and 
alveoli,  causing  the  fine  crackling  sound  of  crepitant 
rale.*  This  is  my  understanding  of  the  seat  of  inflamma- 

*  In  later  papers  the  seat  of  crepitant  rale  is  placed  in  the  pleura. 


ON   PNEUMONIA.  2i 

The  practical  teaching  of  these  views,  connected 
with  the  knowledge,  for  which  we  are  so  much  indebt- 
ed to  Dr.  Clark,  of  the  pathological  discovery  of  the 
non-puriform  character  of  the  exuded  matter  in  pneu- 
monia, is,  that  treatment  may  certainly  abort  the  dis- 
ease in  the  first,  or  stage  of  engorgement,  and  that  it  is 
frequently  possible  in  the  second,  or  stage  of  active  in- 
flammation, denoted  by  crepitus ;  at  all  events,  before 
consolidation,  the  disease  may  be  modified  and  short- 
ened, adding  much  to  the  safety  of  the  patient.  But 
when  the  third  or  exudative  stage  has  taken  place,  the 
duty  of  the  physician  will  be  confined  mostly  to  hygi- 
ene and  intelligent  observation. 

More  extended  experience  has  proved  to  me  that  the 
seat  of  crepitant  rale  is  almost  always  interpleural. 

The  above  explanation  may  be  competent  in  a  degree 
after  the  lung  has  become  adherent  to  the  chest  wall ; 
but  centric  pneumonia  without  interpleural  plastic  exu- 
dation is  unaccompanied  with  rales,  either  crepitant  or 
sub-crepitant,  nor  is  there  bronchial  breathing.  And, 
again,  crepitant  rale  may  exist  without  pneumonia,  as 
when  interpleural  adhesions  are  very  close  and  do  not 
allow  of  but  slight  movement  of  the  lung  almost  at  the 
end  of  forced  respiration,  when  there  will  be  a  little 
shower  of  crepitant  rale. 

mation  in  pneumonia,  and  the  significance  of  the  sign  of 
crepitant  rale. 


24  DISEASES  OF  THE  HEART  AND  LUNGS. 


II. 

Pleuritis* 

Mr.  President:  I  desire  to  restate  some  of  the  points 
in  the  paper  under  discussion — to  make  some  explana- 
tions— to  give  some  instances,  in  order  that  its  meaning 
may  not  be  misunderstood. 

The  underlying  thought  in  the  paper,  which  caused 
it  to  be  written,  is,  that  pleuritic  adhesions  confine  the 
motion  of  the  lung,  cause  systemic  irritation,  acceler- 
ate the  heart-beat,  disturb  the  digestive  function,  lower 
the  vital  power,  and  render  the  occurrence  of  active 
phthisis  probable,  especially  where  there  is  inherited 
tubercular  predisposition.  My  experience  in  public 
institutions  and  private  practice,  which  is  somewhat 
extended,  has  fixed  the  thought  in  my  mind,  and  ever 
since  it  has  taken  shape  I  have  been  at  pains  to  verify 
the  opinion  in  physical  examinations  and  at  autopsies. 
I  have  not  kept  statistical  tables,  yet  I  can  truly  state 
that  in  a  large  proportion  of  the  cases  of  phthisis  that 
I  have  examined,  pleuritic  adhesions  could  be  clearly 
and  unmistakably  made  out.f  Frequently,  too,  a  history 
could  be  obtained  dating  the  time  of  the  pleuritis,  and 
showing  that  it  was  the  cause  of  the  deterioration  of 

*  A  paper  on  Pleuritis  was  read  before  the  Academy  of  Medicine, 
March  17,  1870,  which  was  not  printed.  On  the  7th  of  April  the  follow- 
ing paper  was  read,  in  which  the  leading  points  of  the  former  paper  are 
considered. 

f  In  the  post-mortem  examinations  recorded  in  the  works  of  Laennec 
on  the  chest  and  of  Louis  on  phthisis,  pleuritic  adhesions  were  found  in 
the  great  majority  of  cases. 


PLEURITIS.  2$ 

health  precipitating  consumption.  I  believe  these  facts 
have  not  been  sufficiently  recognized  by  the  profession, 
and  farther,  I  hope,  more  attention  being  directed  to 
this  subject,  we  may  be  enabled  to  prevent  the  unhappy 
result. 

It  is  plain  that  the  stronger  and  more  extensive  tlie 
adhesions  are,  the  more  the  lung  will  be  bound  down 
and  crippled,  and  its  capacity  for  vitalizing  the  blood 
will  be  diminished. 

This  variety  of  adhesions  is  the  result,  generally,  of 
the  most  acute  form  of  inflammation  of  the  chest — 
pleuro-pneumonia.  The  prodromata  are  violent — there 
is  great  congestion.  The  friction  sound  of  pleuritis  is 
heard  before  the  crepitant  rale  of  pneumonia,  and  both 
precede  dulness.  This  sthenic  form  of  inflammation 
occurs  mostly  in  hill  countries,  but  is  occasionally  met 
with  in  cities,  especially  in  children.  It  may  be  aborted 
by  heroic  treatment,  taken  in  time,  as  by  the  sedative 
action  of  calomel. 

Case  I. — C.  N.,  aged  3-1  years,  was  taken  sick  August 
12,  1869.  On  the  14th  he  became  much  Avorse,  looked 
alarmingly  ill,  and  the  doctor  was  sent  for.  On  the 
15th  the  pulse  was  138;  respiration,  70;  ratio,  1.9;  tem- 
perature, i04.|-°.  He  was  given  calomel  thi"ee  grains, 
and  tincture  of  aconite  half  a  drop,  with  sweet  spirits 
of  nitre.  On  the  i6th  I  saw  him  in  consultation.  Pulse, 
120;  respiration,  64;  ratio,  1.8;  temperature,  104. 
Physical  signs  :  Friction  murmur  of  the  pleura;  mufBed 
respiratory  murmurs,  with  commencing  crepitant  rales. 
The  beginning  of  pleuro-pneumonia  was  recognized, 
and  it  was  proposed  to  abort  the  disease.  Eight  grains 
of  calomel  were  given  at  once,  and  one  drop  of  the 
strong  tincture  of  aconite  root  every  hour  till  three 
drops  were  given,  when  all  treatment  was  omitted.  On 
the  17th — pulse,  98;  respiration,  40;    ratio,  2.4;    tern- 


26  DISEASES   OF   THE   HEART   AND   LUNGS. 

perature,  99.  i8th — pulse,  100;  respiration,  32;  ratio, 
3.1 ;  temperature,  98.  The  disease  \^s  aborted,  no  ad- 
hesions, no  depression  of  vital  powen 

Case  2*' — A  gentleman  died  in  this  city  last  November, 
not  quite  60  years  of  age,  gradually  worn  out  with  con- 
sumption. He  was  born  at  Great  Barrington,  Mass., 
where  his  early  life  was  spent.  All  his  family  but  him- 
self were  of  notably  robust  constitutions,  he  only  being 
thin  and  delicate.  He  dated  his  feeble  health  from' the 
time  of  a  violent  inflammation  of  the  chest  when  quite 
young.  When  I  first  saw  him  he  stated  that  his  chest 
disease  was  of  long  standing,  and  physical  examination 
discovered  phthisis  advanced  to  the  third  stage  in  both 
lungs,  with  old  adhesions  in  the  lower  part  of  the  left 
lung,  which  were  supposed  at  the  time  of  the  examina- 
tion to  have  resulted  from  his  childhood  inflammation. 
It  was  believed  to  have  been  one  of  those  cases  where 
a  predisposition  to  phthisis  had  been  acquired  from  de- 
pressed vital  power  by  crippling  the  action  of  the  lung. 
The  two  cases  were  ahke,  I  think,  at  their  beginning ; 
one  was  aborted,  no  damage  remaining;  the  other 
passed  through  the  course  of  the  inflammation,  and  the 
consequence  followed.  I  should  now  classify  this  as  a 
case  of  fibroid  phthisis,  third  stage,  for  there  were  no 
cavities. 

Subacute  pleuritis  has  its  home  in  cities,  or  wherever 
there  is  a  general  lowering  of  vital  power.  Pleuro- 
pneumonia is  a.n  infrequent  disease — that  is,  of  the 
sthenic  variety.  Since  this  articie  was  written,  pleuro- 
pneumonia of  an  asthenic  type  has  become  common. 
Subacute  pleuritis  is  of  common  occurrence  ;  it  fre- 
quently is  w^ithout  much  pain,  or  none  at  all,  and  some- 
times without  the  disturbing  conditions  which  are  usual. 
The  effusion  may  pass  off  without  damage,  either  from 
crippling   adhesions  or  purulent  change ;    and  yet  in 


PLEURITIS.  2J 

every  case  there  is  danger  that  harm  may  result,  and 
this  danger  is  nluch  increased  by  improper  interference, 
and  especially  by  the  use  of  kidney-irritating  diuretics, 
or  plastic  exudation-stimulating  blisters. 

I  feel  quite  sure  that  adhesions  of  a  vital  depressing 
character  may  be  the  result  of  subacute  pleuritis  with- 
out treatment,  but  much  more  so  when  blisters  have 
been  actively  used.  Blisters  in  subacute  pleuritis  cause 
new  adhesions  of  the  same  strong,  binding  character  as 
those  formed  in  the  acute  variety  of  pleuro-pneumonia. 

Since  the  commencement  of  this  discussion  I  have 
verified,  as  I  think,  more  than  one  case  of  the  damaging 
result  of  binding  adhesions ;  but  the  following  will  suf- 
fice :  A  professional  friend  in  the  upper  part  of  the  city 
sent  his  servant  to  me  for  examination.  The  history 
was  that  she  had  subacute  pleuritis  with  effusion  some 
months  ago.  Before  this  her  health  was  good ;  since, 
she  has  had  cough,  fever,  and  chills,  with  some  night- 
sweats  latterly. 

Physical  Examination. — Left  lung  crippled  by  strong 
adhesions  inferiorly  and  posteriori 37^  so  that  full  expan- 
sion does  not  take'  place.  The  evidence  of  these  adhe- 
sions is  very  plain  and  unmistakable.  In  the  right  lung, 
at  the  interscapular  space,  there  are  evidences  of  con, 
solidation  and  active  progress  of  tuberculization.  Ef- 
fect following  cause  could  hardly  be  better  demonstrated 
than  in  this  case ;  and  yet  it  is  not  an  exceptional  one, 
for  it  was  the  frequent  occurrence  of  just  such  cases 
that  first  drew  my  attention.  I  could  multiply  these 
instances,  Mr.  President ;  but  I  think  it  is  sufficient  to 
direct  the  attention  of  observers  to  this  fact,  in  order 
that  their  experience  should  satisfy  them  of  the  truth 
of  their  position. 

Adhesions  that  depress  the  vital  power  prevent  mo- 
tion of  the  lungs,  and  consequently  must  be  in  the  mid- 


28  DISEASES   OF  THE   HEART  AND   LUNGS. 

die  or  lower  part  of  the  pleura.  We  are  thus  enabled 
to  make  a  clear  distinction  in  our  diagnosis.  Pleuritic 
adhesions,  intercurrent  of  phthisis,  and  which  are  con- 
servative in  their  effect,  always  take  place  in  the  immedi- 
ate vicinity  of  the  active  disease,  and  of  course  are  mostly 
in  the  upper  part  of  the  lung.  These  are  always  limited 
by  the  extent  of  the  tuberculosis ;  they  enforce  rest  in 
the  diseased  part,  check  progress,  and  prevent  perfora- 
tion of  the  pleura.  Conservative  adhesions  are  in  the 
upper  part  of  the  lung,  damaging  adhesions  in  the 
lower  part;  damaging  adhesions  take  place  before 
tubercular  activity  ;  conservative  adhesions  only  after 
advanced  phthisis.  My  views  in  regard  to  adhesions 
and  tuberculosis  have  been  essentially  modified  by 
more  extended  experience,  as  will  be  seen  in  succeed- 
ing papers. 

Tubercular  deposits,  which  are  hastened  by  the  de- 
pression consequent  upon  binding  adhesions,  always 
appear  in  their  natural  place,  that  is,  in  the  upper  part 
of  the  lung,  and  quite  frequently  in  the  opposite  lung. 

I  deem  this  subject  important  and  not  trivial ;  and  if 
I  am  not  much  mistaken,  the  ground  taken  in  the  paper 
in  respect  to  adhesions  and  active  phthisis,  as  cause  and 
effect,  will  be  demonstrated  by  future  unbiassed  observ- 
ers, and  a  recognition  of  the  fact  will  enable  us  to  ap- 
ply the  remedy,  doing  away  with  diuretics  and  blisters, 
which  are  damaging,  and  resorting  to  supporting  and 
anti-tubercular  remedies. 

The  next  important  question  is.  How  shall  we  get  rid 
of  the  effusion  of  serum  when  it  refuses  to  pass  off  in 
the  natural  way  ?  From  the  ground  that  I  have  already 
taken  in  regard  to  diuretics  and  blisters,  I  must  reassert 
the  opinion  that  their  use  in  these  cases  should  be  ab- 
stained from  altogether.  The  only  proper  method  of 
removing  the  fluid  innocuously,  when  Nature  is  unable 


PLEURITIS.  29 

to  do  it  in  her  own  way,  is  by  the  trochar  and  canula, 
in  the  method  so  ably  demonstrated  more  than  250  times 
by  our  distinguished  countryman,  Dr.  Bowditch,  who 
honors  us  by  his  presence  here  to-night. 

How  soon  after  the  effusion  has  taken  place  should  it 
be  removed  ?  Nature,  when  uncomplicated  and  not  in- 
terfered with,  removes  in  her  own  way  all  the  fluid  in 
from  two  to  four  weeks.  I  believe  the  separation  of  the 
pleural  surfaces,  after  their  inflammation  long  enough 
to  prevent  adhesions,  is  conservative,  and  in  this  we 
may  safely  follow  her  lead ;  but  if  it  remain  three  or 
four  weeks,  and  show  no  disposition  to  pass  off,  it  should 
be  removed  by  the  canula.  Dyspnoea  or  other  urgent 
circumstances  may  make  it  necessary  to  do  it  much 
earlier,  and  then  it  may  be  only  partially  removed  and 
conservative  action  still  be  observed.  I  have  known  a 
number  of  cases,  where  the  fluid  obstinately  refused  to 
pass  off  under  the  use  of  diuretics  and  blisters,  speedily 
get  well  under  the  treatment  of  rhubarb  and  soda. 
One  such  occurred  but  lately,  in  a  young  lady  in  this 
city.  Miss  M.,  aged  16  3^ears.  1  saw  her  on  the  28th  of 
January,  1870,  in  consultation:  the  left  pleural  cavity 
was  filled  with  fluid,  which  resisted  the  usual  treatment, 
and  the  heart  was  pressed  far  over  to  the  right,  and 
incapacity  of  the  aortic  valve  could  be  made  out  in  that 
position  by  the  aortic  obstructive  systolic,  and  aortic 
diastolic  regurgitant  murmurs.  Diuretics,  etc.,  were 
stopped,  and  she  was  placed  on  rhubarb  and  soda.  I 
saw  her  again  on  the  29th  of  March,  in  consultation, 
and  learned  from  the  attending  physician  that  under 
this  simple  treatment  the  effusion  very  soon  passed 
away.  Examination  at  this  time  showed  that  the  lung 
had  fully  expanded,  and  was  not  damaged  by  adhesions. 

In  conclusion,  Mr.  President,  the  opinions  and  doc- 
trines advanced  in  this  paper  may  not  harmonize  en- 


# 
30  DISEASES   OF   THE   HEART   AND   LUNGS. 

tirely  with  those  accepted  by  the  profession ;  but  I  have 
only  to  say  that  they  are  sincere  convictions,  and  are 
the  result  of  some  experience,  and  I  olace  them  before 
you  for  your  deliberate  judgment,  with  an  earnest  desire 
for  the  success  of  truth. 

Dr.  Peaslee  said  that  Dr.  L.  wrote  on  the  assump- 
tion of  two  propositions :  first,  that  acute  pleuritis  is  a 
serious  disease ;  and  second,  that  the  occurrence  of  ad- 
hesions is  a  serious  result.  Though  not  claiming  to  be 
an  expert.  Dr.  P.. has  seen  much  of  pleuritis,  and  was 
surprised  to  hear  it  questioned  whether  acute  pleuritis 
was  serious,  or  whether  adhesions  were  serious.  He 
agrees  with  Dr.  L.  in  the  importance  of  the  subject, 
otherwise  we  should  have  no  interest  in  the  paper.  If 
the  disease  occur  we  have  three  indications :  subdue 
inflammation,  get  rid  of  the  fluid,  and  prevent  adhesion. 
And  here  it  is  important  that  we  pay  more  attention  to 
the  conditions  under  which  adhesions  occur.  It  has 
been  advanced  that  adhesions  may  occur  without  exu- 
dation ;  that  they  may  be  from  proliferation  of  connect- 
ive tissue,  which,  if  true,  and  without  inflammation,  has 
nothing  to  do  with  the  present  topic.  Confining  our- 
selves to  effusion  and  exudation,  we  must  not  forget 
that  they  are  different  events.  Effusion  is  simply  the 
pouring  out  of  serum,  while  exudation  is  the  pouring 
out  of  blood,  minus  the  corpuscles.  Effusion  is  not 
necessarily  the  event  of  inflammation  ;  for  we  may  have 
hydrothorax  from  disease  of  the  heart,  or  from  conges- 
tion and  derangement  of  the  liver,  without  pleuritis. 
We  may  also  have  ascites  with  no  peritonitis.  Now 
there  are  four  conditions  under  which  adhesions  occur, 
ist,  there  must  be,  not  effusion,  but  exudation ;  2d,  the 
exuded  fluid  must  coagulate;  3d,  the  presence  of  epi- 
thelium ;  4th,  the  two  surfaces  must  be  in  contact.  The 
reason  that  adhesions  are  less  common  in  the  lower  part 


PLEURITIS.  31 

of  the  thorax  is  that  the  pleural  surfaces  are  more  con- 
stantly in  motion  by  the  action  of  the  diaphragm  in 
respiration. 

In  treatment,  it  is  important  that  we  make  the  distinc- 
tion between  acute  pleuritis,  as  Dr.  Learning-  describes 
it,  and  effusion  from  other  causes.  In  simple  hydrothorax 
we  need  not  fear  adhesion,  but  the  patient  Avill  suffer 
from  compression.  In  actual  pleuritis,  where  we  have 
exudation,  we  may  prevent  adhesion  by  removing  the 
fluid,  if  coagulation  has  not  already  commenced.  He 
believes  this  will  yet  be  done  in  orchitis  and  peritonitis. 
If  the  fluid  be  not  removed,  we  may  diminish  the  coagu- 
lability by  administering  calomel  and  alkaline  remedies. 
He  has  no  experience  in  blisters  in  the  treatment  of  this 
disease,  and  never  applies  a  blister  to  remove  the  cuticle ; 
but  whenever  he  applies  one  he  removes  it  as  soon  as 
vesication  has  commenced,  and  applies  a  poultice.  In 
this  way  he  has  never  seen  any  harm  result  from  their 
use. 


32  DISEASES   OF   THE   HEART   AND   LUNGS. 


III. 

Respiratory  Murmurs  * 

Since  the  time  of  Laennec  those  engaged  in  investi- 
gating physical  conditions  of  the  chest  have  ever  united 
in  looking  to  the  breath-sounds  for  the  elementary  key. 

Able  and  distinguished  men  have  given  much  of  their 
lives  to  the  consideration  and  practice  of  auscultation, 
but  certainty  in  diagnosis  in  incipient  disease  is  yet 
vainly  desired.  It  must  be  that  the  method  of  study 
has  been  faulty,  or  that  attention  has  been  wrongly  di- 
rected. Under  these  circumstances  presumption  may 
be  pardoned,  even  if  it  should  fail  in  the  attempt  to 
show  a  better  way. 

Laennec  recognized  both  bronchial  and  pulmonary 
breath-sounds,  and  explained  them  as  being  caused  by 
air-friction.  In  describing  pulmonary  respiration,  he 
says  :  *'  On  applying  the  cylinder,  with  its  funnel-shaped 
cavity  open,  to  the  breast  of  a  healthy  person,  we  hear, 
during  inspiration  and  expiration,  a  slight  but  extremely 
distinct  murmur,  answering  to  the  entrance  of  the  air 
into  and  expulsion  from  the  air-cells  of  the  lungs.  This 
murmur  may  be  compared  to  that  produced  by  a  pair 
of  bellows  whose  valve  makes  no  noise,  or,  still  better, 
to  that  emitted  by  a  person  in  a  deep  and  placid  sleep, 
who  takes  now  and  then  a  profound  inspiration"  (Forbes's 
Laennec,  p.  29) ;  and  the  translator  adds  in  a  foot-note : 
"  It  will  be  most  easily  and  distinctively  perceived  by 
applying  the  naked  ear  to  the  chest  of  a  child."  Laen- 
nec's  view  is  theoretical,  not  based  on  a  careful  study  of 

*Read  before  the  Academy  of  Medicine,  January  4,  1872, 


RESPIRATORY    MURMURS.  33 

all  the  facts.  Indeed,  at  that  time  the  minute  anatomy 
of  the  lung,  and  the  constitution  of  the  residual  air, 
were  not  known.  Subsequent  opinions  have  been  in- 
fluenced more  or  less  by  Laennec's,  especially  in  this, 
that  all  respiratory  murmurs  are  considered  to  be  air- 
and  tube-friction  sounds.  Many  differ  from  him  as  to 
the  seat,  but  all  agree  with  him  as  to  the  mechanism. 
M.  Beau,  of  Paris,  placed  its  seat  in  the  pharynx  ;  Dr. 
Sanderson,  of  Edinburgh,  in  the  rima  glottidis.  Skoda, 
of  Vienna,  considered  vesicular  murmur  as  occurring 
only  in  inspiration,  and  being  caused  by  air-friction,  and 
he  likened  it  to  the  noise  one  makes  in  forcing  the  air 
through  the  nearly-closed  lips.  He  denies  that  the  re- 
spiratory murmur  has  anything  to  do  with  the  vesicu- 
lar breathing,  which,  he  says,  is  a  purely  bronchial 
sound.  Andral  called  it  a  sound  of  pulmonary  expan- 
sion or  vesicular  respiration,  thus  designating  its  seat, 
and  giving  it  name. 

Many  speak  of  vesicular  and  respiratory  murmurs  as 
interchangeable  terms.  The  late  Dr.  Hyde  Salter 
placed  the  seat  of  the  respiratory  or  vesicular  murmur 
in  the  convective  system,  and  mostly  in  the  sub-pleural, 
minute  bronchioles  {British  and  Foreign  Med.-Chir.  Rev.y 
July,  1861).  Dr.  Waters,  of  Liverpool,  whose  prize  es- 
say on  the  minute  anatomy  of  the  human  lung  has  done 
so  much  to  increase  our  knowledge  on  this  subject,  de- 
scribes the  mode  of  connection  of  the  bronchioli  with 
the  air-sacs.  The  opening  sometimes  is,  as  it  were,  a 
hole  punched  out,  clean  and  round,  and  the  air,  passing 
in  and  out,  must  make  a  sound  much  in  the  same  way 
as  is  done  in  a  toy  tin  whistle.  The  late  Dr.  Cammann, 
of  this  city,  believed  the  cause  of  the  murmur  to  be  the 
passage  of  air  into  the  air-sacs  and  out  again.  Dr.  Wil- 
liams, after  speaking  of  portions  of  the  chest  where 
blowing  sounds  are  heard,  goes  on  to  say  ;  "  Then  there 


34  DISEASES   OF  THE   HEART  AND   LUNGS. 

is  the  vesicular  respiration,  which  is  heard  in  most  other 
parts  of  the  chest ;  it  is  a  diffused  murmur  caused  by 
the  air  penetrating  through  the  minutest  tubes,  and 
into  their  numerous  vesicles  or  cells."  Dr.  Gerhard,  of 
Philadelphia  ("  Lectures  on  the  Diagnosis,  Pathology-, 
and  Treatment  of  Diseases  of  the  Chest"),  says  :  "  The 
sound  of  air  entering  the  vesicles  is  different  from  that 
caused  by  its  passage  through  the  tubes,  and  the  former 
is,  therefore,  known  as  the  vesicular  sound,  the  latter  as 
the  tubal  or  blowing  sound.  The  vesicular  sound  is 
often  called  a  murmur,  from  its  softness  and  diffusion 
over  a  large  space,  and  cannot  be  produced  unless  the 
vesicles  are  healthy  or  nearly  so."  And  again  he  says 
the  cause  of  difference  "  seems  to  be  the  different  man- 
ner in  which  the  air  impinges  upon  the  vesicles  and 
tubes.  But  the  vesicular  sound  is  in  part  owing  to  the 
vibration  of  the  air,  and  in  part  to  the  noise  produced 
by  the  dilating  of  the  vesicles  themselves."  * 

Dr.  Walshe  represents  the  natural  respiratory  mur- 
murs as  caused  by  inspiration  and  expiration,  for  which 
there  is  usually  a  healthy  type,  "  commonly  termed — ^, 
pulmonary  or  vesicular ;  b,  bronchial ;  c,  tracheal ;  d, 
laryngeal ;  ^,  pharyngeal,  according  to  the  part  of  the 
respiratory  apparatus  from  which  the  sounds  audible 
externally  are  transmitted."  Dr.  Corrigan  divides  the 
sounds  heard  in  auscultation  into  *'  simple  sounds  or 
murmurs,  and  compound  sounds  or  rattles.  .  .  .  All 
the  sounds  heard  in  the  chest  belong  to  one  or  the  other 
of  those  two  kinds ;  and,  if,  when  you  hear  a  sound, 
the  exact  nature  of  which  you  may  be  in  doubt,  you 
will  first  refer  it  to  its  class,  your  labor  in  determining 
what  it  is  will  be  very  much  diminished."     The  Amer- 

*  Dr.  Gerhard's  views  of  the  mechanism  of  respiratory  murmurs  are 
very  similar  to  those  put  forth  in  this  article. 


RESPIRATORY   MURMURS.  35 

ican  editor  of  "  Stokes  on  the  Chest"  describes  vesicu- 
lar murmur  as  that  "  of  a  soft  and  gentle,  or,  as  it  has 
been  otherwise  described,  a  mellow,  continuous,  gradu- 
ally-developed, breezy  murmur,  unattended  with  a  sen- 
sation either  of  dryness  or  humidity  ;  and  we  are  prop- 
erly cautioned  by  M.  Fournet  and  his  reviewer  not  to 
expect  a  character  of  sound  which  conveys  the  notion 
of  a  successive  dilatation  of  separate  vesicles,  or,  as  it 
is  sometimes  called,  pure  and  vesicular."  Dr.  Hyde 
Salter  says :  ''  There  is  another  reason,  to  which  I  have 
not  referred,  which  makes  me  think  that  the  respiratory 
murmur  must  have  a  tubular  or  ^zcasz  tubular  seat,  and 
cannot  be  formed  in  the  air-cells ;  it  is,  that  fine  crepita- 
tion, such  as  that  of  pneumonia,  supplants  it;  it  does  not 
merely  drown  it,  it  supplants  it;  the  two  do  not  coex- 
ist;" and  farther  on:  *'  If,  then,  pneumonic  crepitation 
is  a  veritable  tube-sound,  and  its  seat  the  microscopical 
tubes  immediately  subtending  the  air-cells,  the  supplant- 
ing and  destruction  of  the  respiratory  murmur  by  it 
would  show  that  this  latter  has  an  identical'  seat,  and  is 
therefore  a  tube-sound."  This  explains  Dr.  Salter's 
views  as  to  the  seat  and  cause  of  the  murmur.  He  be- 
lieves it  to  be  caused  by  the  passage  of  air  through 
these  microscopic  air-tubes,  just  before  they  reach  the 
vesicles ;  and,  as  he  is  one  of  the  latest  and  most  bril- 
liant writers  on  this  subject,  perhaps  he  represents  the 
more  advanced  views  of  the  profession.  He  does  not 
deny  that  sounds  formed  anywhere  in  the  convective 
system,  from  the  mouth  or  nose  to  the  smaller  bronchia, 
mingle  with  and  enter  into  the  composition  of  the  re- 
spiratory murmur,  but  he  denies  that  the  air-vesicles  or 
alveoli  have  anything  to  do  in  forming  the  sound.  He 
believes  the  sound  is  formed  in  the  bronchioles,  imme- 
diately subtending  the  pulmonary  pleura. 

Carefully  examining  the  opinions  of  different  writers, 


36  DISEASES   OF  THE  HEART   AND   LUNGS. 

it  is  evident  that  some  consider  the  respiratory  murmur 
as  having  a  single  seat  and  cause,  while  others  recog- 
nize its  composite  character.  Yet  I  am  not  aware  that 
any  one  has  ever  attempted  to  analyze  the  murmur,  and 
study  its  constituents  separately  as  well  as  together. 
They  speak  of  the  vesicular  character,  the  pulmonary 
quality  of  the  respiration,  but  they  attempt  no  analysis. 
To  show  that  this  may,  and  ought  to  be  done,  in  order 
to  attain  unto  a  higher  grade  of  excellence  in  diagnosis, 
is  the  main  object  of  this  paper.  A  clear  understanding 
of  this  whole  matter  will  make  it  necessary,  as  prelimi- 
nary, to  look  at  the  minute  anatomy  of  the  tissue  of  the 
lungs,  and  of  the  bronchial  system  ;  secondly,  the  cir- 
culation of  the  lungs  and  of  the  bronchial  system ;  and, 
thirdly,  the  characteristics  and  constitution  of  the  re- 
sidual air,  its  object  and  ofhce.  The  bronchial  system 
may  be,  and  is  frequently,  called  the  convective  or  the 
broncho-respiratory  system,  and  the  pulmonary  is  called 
the  'true  respiratory  system.  They  differ  in  almost 
every  respeet.  The  office  of  the  broncho-respiratory  is 
to  convey  air  into  the  true  respiratory  system,  while 
the  true  respiratory  system  is  where  the  great  function 
of  vitalizing  the  blood  is  perfected.  The  bronchial  sys- 
tem is  characterized  by  cartilage  in  its  fibrous  sheath. 
In  the  upper  part,  where  it  is  necessary  to  prevent  col- 
lapse of  the  tubes,  the  cartilage  is  in  nearly  perfect 
rings,  but  as  the  tubes  pass  into  the  lung-structure, 
where  they  are  occupied  by  the  residual  air,  the  carti- 
lage gradually  loses  the  character  of  rings,  and  appears 
merely  as  deposits  occurring  at  irregular  intervals, 
down  so  far  as  the  bronchial  arteries  extend,  to  where 
the  bronchial  veins  commence  to  carry  back  the  blood 
that  has  passed  through  the  capillaries  of  the  bronchial 
mucous  membrane.  The  mucous  membrane  also  of  the 
broncho-respiratory  system,  is  different  from  that  of  the 


RESPIRATORY   MURMURS.  37 

true  respiratory  system  in  this,  that  it  is  ciliated  epithe- 
Kal  mucous  membrane,  while  the  other  is  of  tesselated 
basement  epithelium."^  The  circulation  also  is  entirely 
different.  The  convective  system  is  supplied  by  the 
bronchial  arteries ;  the  pulmonary  substance  by  the 
pulmonary  artery,  and  by  the  nutrient  arteries  of  the 
lungs,  which  are  the  connecting  link  between  the  two 
systems.  The  nutritive  arteries  arise  from  the  bron- 
chial arteries,  but  have  no  accompanying  veins.  Thus, 
blood,  after  performing  the  proper  office  of  nutrition  in 
the  pulmonary  tissue,  is  at  once  reaerated,  and  passes 
into  the  venous  radicles  of  the  pulmonary  vein  prepared 
for  systemic  circulation.f 

The  bronchial  arteries  have  been  called  the  nutritive 
arteries  by  anatomists,  but  they  have  not  dwelt  upon 
the  fact  that  the  vence  comites  do  not  attend  these  arter- 
ies into  the  pulmonary  structure,  and  that,  consequently, 
this  gives  them  a  peculiar  character.  The  bronchial 
veins  return  all  the  blood  of  the  bronchial  arteries ;  the 
nutritive  arteries  have  no-  veins.  Their  blood  is  re- 
aerated  where  they  do  their  work,  and  it  finds  its  way 
into  the  venous  radicles  of  the  pulmonary  vein  as  ar- 
terial blood.  This  anomaly  in  the  circulation  is  of 
great  interest  in  explaining  physiological  causes  and 
pathological  effects.  In  pneumonia  it  is  the  nutrient 
artery,  accompanied  with  its  plexes  of  ganglia  of  the 
organic  nerve,  lymphatics,  etc.,  that  preserves  the  life, 
of  the  part,  and  governs  the  whole  process  of  resolution. 
We  can  all  remember  the  anxiety  of  practitioners,  in 

*The  ciliated  columnar  epithelium,  so  characteristic  of  the  bronchial 
mucous  membrane,  ceases  at  the  commencement  of  the  alveoli.  (Dr. 
Waters  "On  the  Chest,"  1868.) 

f  Ibid.,  pp.  16,  17.  Also,  Strieker's  "  Histology,"  1872,  p.  443;  Nie- 
meyer,  vol.  i.  p.  60;  Wilson's  "Anatomy,"  p.  514,  1859;  Gray's  "  An- 
atomy," p.  720. 


3S  DISEASES  OF  f  lii:  heart  and  lungs. 

the  past,  to  prevent  abscess  and  gangrene  of  the  lun^ 
after  inflammation.  But  time,  and  a  more  careful  study 
of  the  natural  history  of  the  disease,  have  proved  to  us 
that  gangrene  and  abscess  are  rare  accidents,  even 
when  no  treatment  at  all  is  had.  This  peculiar  arrange- 
ment of  the  nutrient  artery  gives  us  an  early  knowledge, 
in  many  cases,  of  commencing  phthisis.  Occupation 
of  the  air-sacs  by  tubercle  interferes  with  the  circula- 
tion, and  blood  is  thrown  back  upon  the  bronchial  ar- 
tery, and  the  result  is  bronchorrhagia,  a  conservative 
act;  for,  like  the  application  of  leeches,  it  sets  the 
absorbents  actively  at  work  to  remove  the  cause — the 
new  tubercle.  And,  in  this  way  cases  of  early  phthisis 
are  self-cured,  or,  at  all  events,  ameliorated,  and  the 
physician  is  guided  in  his  treatment. 

This  singular  fact  in  the  circulation  was  discovered 
by  the  late  Dr.  Cammann,  in  making  his  experiments  to 
prove  the  non-anastomosis  of  the  arteries  of  the  lung. 
Using  a  colored  fluid  suitable  for  fine  injections,  he 
found  that,  when  he  injected  the  pulmonary  artery,  the 
fluid  returned  easily  by  the  pulmonary  vein ;  but,  in- 
jecting the  pulmonary  vein,  the  fluid  not  only  passed 
into  the  pulmonary  artery,  but,  if  the  injection  was 
carefully  continued,  it  would  also  find  its  way  into  the 
bronchial  arteries.  Then,  again  injecting  the  bronchial 
arteries,  he  found  that  the  fluid  after  a  little  time  passed 
into  the  pulmonary  vein ;  this  proved  that  there  was 
communication  between  the  bronchial  arteries  and  the 
pulmonary  vein,  but  not  with  the  pulmonary  artery.* 
This  was  shortly  after  1840,  and  before,  I  believe, 
any  experiments  had  been  made  in  Europe,  in  regard 
to  this  circulation.  Sin'ce  then,  several  observers  have 
come  to   nearly  the  same  conclusion.     Drs.  Williams 

*  Communicated  to  me  by  Dr.  Cammann. 


RESPIRATORY  MURMURS.  3^ 

and  Adriani  believe  "  the  vessels  of  the  bronchial  mu- 
cous membrane  terminate  in  the  pulmonary  veins,  and 
those  of  the  deeper  plexus  in  the  bronchial  veins."  Dr. 
Waters  says,  after  explaining-  his  experiments,  which 
were  very  full  and  minute:  "That  a  distinct  and  free 
communication  exists  between  the  bronchial  vessels  and 
the  pulmonary  veins  admits  of  ocular  proof.  I  have 
seen,  with  the  aid  of  the  dissecting  microscope,  the 
small  vessels  passing  from  the  outer  surface  of  the 
bronchial  tubes,  and  forming  a  small  trunk,  which  ter- 
minated in  a  pulmonary  vein.' '  Dr.  Waters  also  says  :  * 
**  It  may  be  said  that  such  a  view  militates  against  the 
generally-received  opinion  of  the  purity  of  the  blood 
returned  to  the  left  side  of  the  heart,  for,  if  the  bron- 
chial blood  is  poured  into  the  pulmonary  veins,  it  is 
returned  to  the  left  auricle  without  undergoing  the  pro- 
cess of  aeration.  I  would  answer  that  the  view  I  have 
taken  is  supported  by  anatomical  facts,  a  basis  on  which 
all  physiological  theories  should  be  founded."  I  re- 
member that  Dr.  Cammann,  also,  could  not  reconcile 
the  incongruity  of  the  apparent  fact  that  venous  blood 
passed  directly  into  the  aerated  blood  of  the  pulmonary 
vein,  and  then  to  the  left  heart.  Both  of  these  gentle- 
men overlooked  the  truth  that  the  blood  from  the  nu- 
trient artery  passes  through  capillaries  in  the  true 
respiratory  system  on  its  way  to  the  radicles  of  the 
pulmonary  vein,  and,  of  course,  is  reaerated.  Dr. 
Robert  Lee,  if  my  memory  serves  me  (for  I  have  not 
the  paper  at  hand),  says  that  the  extension  of  the  bron- 
chial artery,  after  it  has  quit  company  Avith  the  vein,  re- 
ceives additions  from  the  mammary  and  intercostal  ar- 
teries, and  has  the  proper  title  of  nutrient  artery.  I  do 
not  quote  his  words,  but  the  substance,  as  I  remember  it. 

*  "  Minute  Anatomy  of  the  Human  Lungs." 


4d  DISEASES   OF  THE  HEART  AND   LUNGS. 

I  believe,  then,  I  am  warranted  in  holding  that  there 
is  a  complete  difference  in  the  blood  vessels  of  the  con- 
vective  and  of  the  pulmonary  systems.  The  nutrient 
arteries  of  the  bronchial  system  have  their  vence 
comifes;  the  nutrient  arteries  of  the  true  respiratory 
system  have  no  accompanying  veins,  but  pass  their 
blood  reaerated  directly  into  the  pulmonary  vein,  pre- 
pared for  systemic  circulation.  The  nutrient  artery  is 
no  exception  to  the  rule  of  complete  difference  in  the 
two  systems,  for  in  its  ofhce  it  belongs  wholly  to  the 
true  respiratory.  The  vessels  of  the  bronchial  system 
are  the  bronchial  arteries  and  veins  ;  the  vessels  of  the 
true  respiratory  are  the  pulmonary  artery  and  vein,  and 
the  nutrient  artery  of  the  lungs. 

Where  the  bronchial  system  ends  the  pulmonary 
begins,  and  the  division  is  sufficiently  marked — it  is 
where  cartilage  ceases  and  alveoli  commence.  The 
structure  of  the  true  respiratory  system  is  composed  of 
terminal  bronchii,  in  which  are  developed  alveoli  and 
the  air-sacs,  that  is,  wherever  alveoli  are  found.  Its 
whole  object  or  office  is  aeration  of  the  blood  of  the 
body.  It  is  greatly  distensible,  and  in  this  differs  from 
the  convective  system,  which  is  but  little  so,  and  its 
formation  evidences  design  in  the  economy  of  space  and 
for  its  especial  purpose.  The  bronchioles  have  alveoli 
developed  in  their  sides,  but  not  to  the  same  extent  as 
in  the  air-sacs,  which  are  but  a  skeleton  network  for  the 
convenient  spreading  out  of  alveoli,  with  their  rete 
mirabile  of  capillaries,  for  the  aeration  of  the  blood. 
The  terminal  bronchus  enlarges  at  its  end,  and  the  air- 
sacs  are  developed  from  this  enlargement,  according  to 
Dr.  Waters,  as  a  cluster  of  leaves  are,  sometimes  from 
the  end  of  a  twig.  From  six  to  thirteen  of  these  air- 
sacs  are  in  connection  with  the  enlarged  end  of  a  ter- 
minal bronchus,  and  this  little  cluster  forms  a  lobulette 


RESPIRATORY   MURMURS.  4I 

— a  complete  type  of  the  whole  lung.  Each  lobulette 
has  its  terminal  bronchus  and  air-sacs  for  the  develop- 
ment of  alveoli,  its  twig  of  pulmonary  artery  and  vein, 
its  branch  of  nutrient  artery,  with  the  accompanying 
ganglias  of  organic  nerve,  lacteals,  absorbents,  etc.  A 
collection  of  lobulettes  form  a  lobule,  and  a  number  of 
these  constitute  a  lobe.  The  fibrous  bands  of  the  bron- 
chial sheath  are  continued,  though  with  great  tenuity, 
through  the  terminal  bronchi  into  the  air-sacs,  both  of 
the  white  and  yellow  variety.  They  surround  the 
mouth  of  each  air-sac,  and  give  firmness  to  the  frame  of 
each  alveolus.  Muscular  fibres  also  accompany  these 
bands,  though  their  presence  is  doubted  on  account  of 
their  extreme  tenuity.  Niemeyer  speaks  of  muscular 
fibres  as  present  in  the  true  respiratory  system.  In 
emphysema,  the  air-sacs  lose  their  power  of  contraction, 
and  become  dilated,  causing  great  suffering  and  disabil- 
ity to  the  patient.  Time  and  freedom  from  catarrh 
allow  the  function  of  contraction,  which  is  a  muscular 
habit,  to  return. 

Physiologists  describe  residual  air  as  filling  the 
respiratory  system  as  high  up  as  the  third  or  fourth 
divisions  of  the  bronchise.  It  not  onty  fills  the  true 
respiratory  system,  but  distends  it.  The  elements  of 
the  distending  force  are :  atmospheric  pressure,  mus- 
cular contraction,  rarefaction,  and  the  laws  of  diffusion 
of  gases,  and  that  of  affinitive  attraction  between  oxygen 
and  venous  blood.  The  residual  air  occupies  its  posi- 
tion with  such  persistence  as  to  be  with  difficulty  dis- 
lodged after  death,  even  with  much  pressure.  It  keeps 
its  place  with  vastly  greater  tenacity,  during  life,  when 
each  element  of  force  is  in  active  operation. 

During  inspiration,  the  contraction  of  the  diaphragm 
increases  the  capacity  of  the  chest,  and  at  the  same 
time  the  epiglottis  is  raised,  and  the  weight  of  the  at- 


42  DISEASES   OF  THE   HEART  AND   LUNGS. 

mosphere  operates  actively  in  dilating  the  lungs.  Rare- 
faction of  the  newly-inspired  air  takes  place  upon  in- 
spiration, owing  to  its  immediate  and  intimate  admix- 
ture with  the  residual  air,  and  is  the  third  element  of 
dilating  force.  The  residual  air  is  estimated  to  be  170 
cubic  inches,  and  the  inspired  air  at  20.  At  each  inspi- 
ration, therefore,  the  residual  air  will  be  increased  about 
one  tenth  in  dilating  power,  plus  the  rarefaction  of  the 
inspired  air.  But  the  peculiar  elements  of  this  expand- 
ing force  are,  the  laws  of  the  diffusion  of  gases,  and 
that  of  the  affinitive  attraction  between  the  unaerated 
blood-globules,  in  the  capillaries  of  the  rete  mirabile  of 
the  alveoli,  and  the  oxygen,  which  is  equally  distributed 
throughout  the  residual  air.  Chemistry  demonstrates 
that  gases  differently  constituted  in  certain  relations  in- 
stantly intermix  when  brought  together.  The  inspired 
air  and  the  residual  air  present  these  differences.  Air 
entering  the  convective  system  moves  in  a  body  through 
the  bronchial  tubes  till  it  meets  the  residual  air,  when, 
the  law  of  the  diffusion  of  gases  operating,  immediate 
admixture  takes  place.  The  residual  air  is  instantly  re- 
newed with  oxygen,  in  accordance  with  this  law.  The 
inspired  atmospheric  air  moves  through  the  convective 
system,  as  far  as  the  fourth  division  of  the  bronchise, 
with  no  other  resistance  than  the  friction  of  the  tubes. 
When  it  meets  the  residual  air,  it  is  immediately  con- 
sumed, as  it  were,  and  does  not  accumulate,  causing  re- 
sistance. On  this  account  the  inspired  air  moves  with 
increasing  velocity,  producing  air- and  tube-friction  mur- 
mur. Tidal  air  in  health  is  only  heard  in  inspiration. 
Velocity  of  the  moving  air  in  the  tube  is  the  cause  of 
murmur.  Any  one  may  demonstrate  this  fact  by 
breathing  through  a  tube  gently,  when  there  will  be  no 
murmur,  but,  if  he  increase  the  velocity  of  the  moving 
air,  he  will  get  sound,  which  will  be  increased  in  sonor- 


RESPIRATORY  MURMURS.  43 

ity  and  raised  in  pitch  just  in  accordance  with  the  rate 
of  motion.  In  health,  in  unconscious  breathing,  expira- 
tion is  not  heard,  and  we  know  by  experience  that, 
when  it  is  heard  in  unconscious  breathing,  there  is 
disease ;  it  may  be  phthisis,  or  it  may  be  emphysema — 
other  conditions  must  determine  which.  A  murmur 
may  be  produced  at  will,  by  hurrying  the  respiration. 
It  is  heard  in  systemic  diseases  like  cholera,  or  in  dis- 
eases of  particular  organs,  as  in  cardiac  apnoea,  or 
Bright's  small  kidney.  The  cause  of  murmur,  in  air 
moving  in  a  tube,  no  matter  what  are  the  other  condi- 
tions, or  the  disease,  is  the  velocity,  increasing  the  air- 
and  tube-friction. 

Prof.  John  W.  Draper  has  given  a  convincing  expla- 
nation, based  on  accurate  experimentation  of  affinitive 
attraction  in  the  systemic  capillaries,  as  one  of  the  effi- 
cient causes  of  the  circulation.  The  same  power  oper- 
ates in  the  pulmonic  circulation,  but  with  this  important 
addition,  that  the  attraction  is  not  alone  in  the  pulmonic 
tissues  and  the  blood,  but  principally  in  the  venous 
blood  and  the  oxygen  of  the  residual  air.  This  is  the 
cause  that  brings  the  venous  blood  and  oxygen  together, 
in  order  that  the  blood  may  be  purified  and  fitted  to 
continue  the  life  of  the  body.  Let  us  endeavor  to  com- 
prehend the  intricate  mechanism  of  the  respiratory  act. 
Inspiration  has  taken  place — tAventy  cubic  inches  have 
been  added  to  the  residual  air,  evenly  and  equally  ad- 
mixed— dilatation  has  taken  place  with  force,  and  is 
continued  and  increased  by  the  rarefaction  of  heat. 
The  true  respiratory  system,  by  its  muscular  power, 
contracts  forcibly,  antagonizing  the  dilating  residual 
air.  Each  particle  of  pure  air,  acknowledging  its  at- 
traction for  the  venous  blood,  presses  up  to  the  alveolus, 
through  the  struggling  mass,  and  rushes  to  the  blood- 
globule  in  the  capillary — makes  the  interchange — gives 


44  DISEASES    OF   THE   HEART   AND    LUNGS. 

up  its  oxygen,  and  receives  in  return  detritus  and  car- 
bon materials,  loses  its  attraction,  becomes  passive,  but 
is  crowded  back  by  other  eager  particles  pressing  for- 
ward, until  finally  it  finds  itself  well  up  in  the  bronchus, 
with  its  filthy  load,  whence  it  is  expired.  The  blood- 
globule  from  the  pulmonary  artery,  entering  the  capil- 
lary of  the  alveolus,  hurries  along  through  the  rete 
mirabile,  drawn  by  its  affinity  for  oxygen,  till  it  meets 
a  particle  of  pure  air,  makes  the  interchange,  loses  its 
activity,  but  is  pushed  onward  by  other  globules  press- 
ing forward  from  behind,  till  it  finds  itself  in  the  venous 
radicle  of  the  pulmonary  vein,  fitted  for  systemic  cir- 
culation. The  movement  of  the  blood-globules  is  much 
assisted  by  the  contraction  and  relaxation  of  the  mus- 
cular fibres  of  the  true  respiratory  system.  Different 
bundles  of  these  fibres,  contracting  and  relaxing  in  suc- 
cession, give  not  only  a  living  vibratory  motion,  which 
assists  in  hurrying  the  globules  along,  but  produce  a 
susurrus,  which,  being  heard  at  the  chest-wall  in  mul- 
titudinous concert,  is  true  respiratory  murmur.  These 
facts  in  minute  anatomy  and  physiology  (and  they 
hardly  admit  of  any  dispute)  prove  that  the  residual 
air,  as  a  body,  has  no  more  motion  than  has  the  bottom 
of  the  deep  sea.  No  change  can  occur  except  moJ.ecu- 
lar,  and  none  other  is  necessary.  The  law  of  diffusion 
of  gases  assures  the  comparative  purity  of  the  residual 
air,  as  well  as  its  constant  and  guarded  impurity,  which 
is  so  necessary  for  the  accomplishment  of  the  vital  act."^ 

*  "  This  diffusion  [of  gases]  is  constantly  going  on,  so  that  the  air  in 
the  pulmonary  vesicles,  where  the  interchange  of  gases  with  the  blood 
takes  place,  maintains  a  pretty  uniform  composition.  The  process  of 
aeration  of  the  blood,  therefore,  has  none  of  the  intermittent  character 
which  attends  the  mechanical  processes  of  respiration."  Flint.  Physi- 
ology, vol.  i.  p.  407. 

*'  Now  it  is  obvious  if  no  provision  existed  for  mingling  the  air  in- 
spired with  the  air  already  occupying  the  lungs,  the  former  would  pane- 


RESPIRATORY   MURMURS.  45 

The  circulation  would  not  go  on  if  each  blood-globule 
should  immediately  come  in  contact  with  pure  air,  for 
then  it  would  lose  its  impelling  force,  and,  all  of  the 
globules  alike  losing  their  attraction,  there  would  be 
stasis.  Instead  of  this,  both  in  the  blood  and  the  resid- 
ual air  each  globule  and  each  air-particle  moves  in  per- 
fect order,  never  in  each  other's  way.  This  shows  how 
the  individual  may  live  in  bad  air  for  a  time,  resisting 
its  evil  tendencies,  and  even  that  of  poisonous  gases.  It 
shows  also  why  medical  inhalations  fail  in  their  object. 
Medicated  vapors  have  little  or  no  admission  into  the 
residual  air.  Even  oxygen  gas,  which  is  sometimes 
serviceable,  can  only  supply  atmospheric  deficiencies. 
It  can  neither  do  the  harm  nor  the  good  that  has  been 
predicated  for  it.  An  animal  may  even  live  for  a  time 
in  pure  oxygen  gas,  the  active  interchange  taking  place 
between  the  gas  and  the  blood  restoring  the  necessary 
grade  of  impurity  in  the  residual  air. 

If,  then,  the  only  change  of  motion  that  is  possible  in 
the  residual  air  be  molecular,  what  becomes  of  the  theo- 
ries of  air-  and  tube-friction  murmurs,  whether  in  the 
smaller  bronchise  or  the  air-sacs  and  alveoli,  as  cause  of 
the  so-called  vesicular  murmur?  They  are  physical 
impossibihties.  And,  too,  what  becomes  of  the  theories 
of  the  mechanism  of  crepitant  rale?  If  there  is  no 
motion  but  the  molecular,  there  can  be  no  bursting  of 
bubbles  in  the  microscopic  tubes,  and  that  theory  falls. 
If  the  residual  air  constantly  and  forcibly  distends  the 
true  respiratory  system,  how  can  the  bronchioles  and 
air-sacs  come  together,  to  be  separated  by  each  inspi- 
ration of  fresh  air,  so  as  to  produce  fine  crepitant  rale  ? 

trate  no  further  than  the  larger  air-passages.  The  change  must  be  at- 
tributed to  the  'mutual  diffusion'  of  gases."  Carpenter,  Physiology, 
Phila.,  1853.  See,  also,  Kirke,  Physiology,  p.  235.  Cyclopaedia  of 
Anat.  and  Phys.,  Lend.,  1847-49,  vol.  iv.  part  i.,  p.  362. 


46  DISEASES   OF   THE   HEART  AND   LUNGS. 

This  theory,  likewise,  supposes  a  physical  impossibility. 
All  theories,  whether  of  vesicular  murmur  or  crepitant 
rale,  which  ignore  the  presence  of  the  residual  air,  are 
of  necessity  incompetent.  The  fact  that  residual  air 
has  none  but  molecular  motion  may  be  demonstrated 
by  a  distensible  bag-,  as  of  India-rubber.  While  it  is 
being  forcibly  filled  with  air,  there  will  be  air-  and  tube- 
friction  murmur  at  the  mouth  only,  where  the  air 
moves  in  a  body  with  velocity.  The  body  of  air  in 
the  bag  will  be  increased  by  particles  of  air  sliding  in 
among  each  other  and  without  sound.  But  there  will 
be  resisting  vibratory  sound  in  the  walls  of  the  tense 
dilating  bag ;  different,  however,  from  that  of  the  con- 
tracting true  respiratory  murmur  in  this,  that  it  is  only 
heard  during  dilatation,  while  the  other  is  continuous, 
because  owing  to  active  muscular  contraction.  Dr. 
Hyde  Salter  says,  after  speaking  of  the  occupancy  of 
the  true  respiratory  system  by  residual  air,  and  that 
about  twenty  cubic  inches  of  atmospheric  air  are  added 
at  each  inspiration  :  "  Each  air-cell  is,  therefore,  a  tenth 
larger  at  inspiration  than  at  expiration.  Now,  it  is  in- 
conceivable that  this  slight  variation  in  the  capacity  of 
these  shallow  open  concavities  should  be  attended  with 
any  sound.  1  cannot  conceive  it  possible.  For,  be  it 
remembered  that  the  air-cells  are  not  nearly-closed  cav- 
ities communicating  by  constricted  orifices  with  the 
general  cavity  of  the  lobular  passage,  but  wide-mouthed 
and  patulous  like  a  teacup.  And  be  it  remembered, 
too,  that  in  respiration  the  air  is  not  pumped  out  of  and 
into  the  cells,  but,  as  they  undergo  this  slight  change 
of  volume,  a  small  part  of  their  contents  passes  just 
without  them,  and  then  again,  on  their  recovering  their 
capacity,  from  without  just  within  them,  if  one  can  speak 
of  '  within '  and  '  without,'  in  reference  to  such  sHght 
interchange  of  situation.     For,  really,  the  renovation  of 


RESPIRATORY   MURMURS.  47 

the  air  in  the  tissues  of  the  lung  does  not  depend  on  its 
actual  removal,  but  upon  the  law  of  the  diffusion  of 
gases." 

This  reasoning  is  cogent  and  unanswerable.  It  proves 
beyond  cavil  that  there  is  no  motion  in  the  air-sacs  and 
alveoli  to  produce  air-  and  tube-friction  sound,  and  yet 
he  attempts  to  show  that  there  is  such  motion  in  the 
smaller  bronchige  and  intralobular  passages.  He  says  : 
*'  But  while  the  movement  of  the  air  at  each  alveolus 
would  be  so  slight,  so  almost  inappreciable,  the  collect- 
ive expansion  of  all  the  alveoli  common  to  a  lobular 
passage,  and  the  consequent  abstraction  of  air  from  the 
general  cavity,  would  be  considerable,  and  would  create 
a  considerable  rush  of  air  into  the  lobular  passage  to 
supply  its  place,  for  the  modicum  of  air,  however  small, 
appropriated  by  each  dilating  air-cell,  would  of  course 
be  multiplied  by  the  number  of  cells  communicating 
with  the  common  axial  cavity  of  the  lobular  passage." 

Dr. -Salter's  able  reasoning  shows  that  there  is  not 
enough  motion  in  the  alveoli  or  air-sacs  to  cause 
sound,  and  it  is  strange  that  he  did  not  see  that  the 
same  reasoning  applies  with  equal  force  to  the  air 
in  the  bronchioles  and  intralobular  passages.  The 
residual  air  occupies  these  passages  just  as  well  as  it 
does  the  air-sacs ;  one  tenth  is  added  at  each  inspira- 
tion to  the  whole  body  of  residual  air,  and  Dr.  Salter 
himself  has  said  that  these  small  bronchial  tubes  were 
largely  distensible  ;  consequently,  the  velocity  of  motion 
in  these  passages  where  alveoli  are  developed  must  be 
too  little,  if  there  be  any  at  all,  to  produce  any  sound. 
There  certainly  can  be  no  rush  ;  indeed,  I  have  already 
shown  that  there  can  be  no  motion,  except  the  molecu- 
lar. But,  for  argument's  sake,  if  there  should  be  motion 
in  these  minute  tubes,  as  Dr.  Salter  claims,  it  could  not 
possibly  have  the  velocity  necessary  to   cause   sound. 


48  DISEASES   OF   THE   HEART  AND   LUNGS. 

Dr.  Salter's  argument  to  prove  that  the  seat  of  crepi- 
tant rale  and  the  seat  of  respiratory  murmur  are  the 
same — ''  The  rale  supplants  the  true  respiratory  mur- 
mur; the  two  do  not  coexist" — heretofore  quoted,  is 
convincing.  Had  he  placed  the  seat  in  the  air-sacs  and 
alveoli  as  well  as  in  the  terminal  bronchioles,  he  would 
have  been  correct,  for  then  he  must  have  acknowledged 
that  it  could  not  be  by  tube-  and  air-friction,  and  he 
would  have  been  forced  to  accept  the  true  explanation, 
that  of  dilatation  and  contraction.  Crepitant  rale  indi- 
cates the  commencement  of  the  process  of  inflamma- 
tion, and  it  supplants  the  true  respiratory  murmur. 
Let  us  study  the  evidence  in  the  light  of  the  true  respi- 
ratory murmur. 

If  you  have  lately  examined  the  chest  of  aperson  in 
health,  and  have  noted  the  murmur  in  its  fulness  and 
perfection,  and  should  be  called  to  see  him  suffering 
from  a  chill,  with  pain  in  the  head,  back,  limbs,  etc., 
and  should  again  examine  the  respiration  carefully, 
you  will  still  hear  the  true  respiratory  murmur,  but  it 
will  be  obscured  or  muffled.  All  the  capillaries  of  the 
lung  are  crowded  with  blood,  and  this  is  the  explana- 
tion of  the  muffled  murmur.  If  you  wait  a  few  hours, 
and  again  examine  him,  you  find  the  true  respiratory 
murmur  absent,  and,  in  place  of  it,  the  fine  crepitant 
rale.  The  congestion  of  the  capillaries  of  the  lung  still 
remains ;  there  is  scarcely  a  perceptible  difference  in 
the  percussion-note ;  the  residual  air  still  occupies  its 
seat  in  the  true  respiratory  system,  and  it  still  continues 
to  dilate  the  air-sacs,  alveoli,  and  terminal  tubes. 
Whatever  change  has  taken  place  must  have  been  at 
the  seat  of  the  true  respiratory  murmur. 

In  tissues  that  may  be  seen,  what  is  the  first  result  of 
inflammation  ?  Is  it  not  that  plastic  material  is  thrown 
out  into  the  connective  tissue  ?     This,  also,  must  take 


RESPIRATORY   MURMURS.  49 

place  ill  the  lungs.  The  connective  tissue  of  the  lungs, 
delicate  as  it  is,  has  been  filled  with  plastic  material.  It 
has  become  thickened  and  stiffened,  it  cannot  contract, 
and  the  true  respiratory  murmur  is  gone,  but  it  must 
yield,  though  unwillingly,  to  the  dilating  force  of  the 
residual  air,  increased  one  tenth  at  each  inspiration, 
separating  newly-formed  plastic  exudations,  causing 
sound,  which  we  hear  as  fine  crackling,  and  call  it 
crepitant  rale.  If  we  wait  a  few  hours  more,  and  ex- 
amine again,  we  will  find  that  crepitant  rale  as  well  as 
true  respiratory  murmur  has  gone,  and  all  is  silent,  or 
there  may  be  bronchial  or  tubular  breathing.  Exuda- 
tion has  been  poured  into  the  true  respiratory  system, 
and  consolidation  is  the  result.  The  seat  of  crepitant 
rale  is  now  become  the  seat  of  exudation. 

If  I  have  studied  this  matter  as  correctly  as  I  have 
carefully,  this  is  the  process  gone  through  with,  and  is 
the  true  mechanism  of  crepitant  rale.  In  this  paper  I 
have  endeavored  to  show  that  the  bronchial  respiratory 
system  is  entirely  different  from  the  true  respiratory 
system  in  anatomy,  physiology,  object,  and  use,  and 
that  the  physical  signs  of  pathological  change  are 
equally  distinct  and  different.  That  the  residual  air, 
occupying,  as  it  does,  the  true  respiratory  system  with 
force,  precludes  the  idea  of  currents  of  air  within  the 
lungs,  and  consequently  the  accepted  theories  of  the 
vesicular  or  respiratory  murmurs  and  of  the  formation 
of  crepitant  rale  are  necessarily  incompetent.  If  my 
points  are  well  taken,  and  the  proof  convincing,  the 
profession  will  eventually  sustain  the  truth,  and  much 
that  has  been  received  as  settled  literature  will  be 
swept  away  as  rubbish,  to  give  room  for  truer  and  bet- 
ter grounds  of  faith. 

The  composite  character  of  the  respiratory  murmur 
must  be  made  evident,  analytically  as  well  as  syntheti- 


50  DISEASES   OF  TB[E   HEART  AND   LUNGS. 

cally.  The  two  elements,  different  in  cause,  character, 
and  seat,  must  be  individually  studied  in  order  that  we 
may  correctly  understand  their  significance  in  patho- 
logical changes.  We  may  present  their  union  and  the 
result  to  the  eye,  thus: 


Broncho-respiratory ' 
murmur. 

True  respiratory 
murmur. 


Respiratory  murmur. 


The  reasons  for  introducing  a  new  terminology  are, 
that  broncho-respiratory  and  true  respiratory  are  de- 
scriptive, and  indicate  the  seat  of  the  murmurs.  The 
term  vesicular  murmur  was  applied  by  Andral,  sup- 
posing that  it  described  the  minute  anatomy  of  the 
seat  of  the  murmur. 

Later  investigations  show  that  the  term  is  misap- 
plied, for  there  are  no  structures  that  may  properly  be 
called  vesicles  in  the  lungs.  Again,  the  terms  vesicu- 
lar and  respiratory  have  been  applied  indiscriminately, 
and  their  present  use  would  lead  to  confusion  and  mis- 
apprehension. 

In  order  to  practically  study  these  murmurs,  it  will 
best  be  done  by  selecting  a  healthy  person  about  twen- 
ty-five years  of  age,  with  perfectly-developed  chest  and 
with  muscles  not  hardened  by  manual  labor. 

RESPIRATORY  MURMUR^. 

Placing  the  eq,r  lightly  yet  firmly  to  the  chest,  allow- 
ing the  head  to  rise  and  fall  with  the  respiration,  listen 
to  the  breath-sounds  of  the  patient,  breathing  with 
him  synchronously.  The  tidal-air  murmur  will  first 
catch  the  ear  as  modified  by  the  true  respiratory  mur- 
mur, and,  as  has  been  described,  is  like  the  sighing  of 
the  tr^es  Qver  our  he^ds  in  the  forest,  when  the  bough§ 


RESPIRATORY   MURMURS.  51 

are  gently  stirred  by  the  breeze.  The  character  and 
quality  of  the  respiratory  murmur  depend  upon  the 
absence  or  excess  of  one  or  the  other  of  the  composing 
elements.  If  the  true  respiratory  murmur  be  maxi- 
mum in  fulness,  the  tidal  air-sound  will  be  short,  only 
heard  in  inspiration,  and  will  be  of  the  soft,  breezy 
character  described  as  gently  sighing. 

While,  if  the  broncho-respiratory  be  in  excess,  the 
tidal-air  sound  will  be  harsh,  raised  in  pitch,  and  will  be 
heard  both  in  inspiration  and  expiration,  and  becomes 
a  sign  of  disease  as  the  other  is  of  health. 

BRONCHO-RESPIRATORY   MURMUR. 

Broncho-respiratory  murmur  may  be  studied  by  forc- 
ing the  breathing,  when  it  will  be  heard  in  both  inspi- 
ration and  expiration,  and  its  harshness,  loudness,  and 
pitch  will  depend  upon  the  force  given  to  the  respira- 
tion.  This  murmur  may  be  heard  in  its  perfection  in 
the  chest  of  a  child,  before  the  true  respiratory  mur- 
mur has  been  developed. 

TRUE  RESPIRATORY  MURMUR. 

The  ear  accustomed  to  auscultation,  after  a  few 
moments  of  concentration  of  the  attention  upon  the 
respiratory  murmur,  will  recognize  its  dual  composi- 
tion. If  the  chest  be  perfect  in  condition,  the  tidal-air 
sound  will  be  heard  in  inspiration  only — soft  and  short, 
like  breathing  gently  through  the  closed  teeth — while 
the  true  respiratory  murmur  will  be  continuous,  in- 
creasing in  fulness  in  inspiration  and  diminishing  in 
expiration.  It  is  of  low  pitch,  and  is  like  the  roaring 
of  the  sea  at  a  distance,  the  waves  breaking  on  an  even 
shore  of  sand ;  or,  better  still,  like  the  sound  made  by 
bees  in  cold  weather,  when  the  hive  is  tapped  with  the 
finger.     It  is  like  the  innumerable  vibrations  of  the 


52  DISEASES   OF  THE   HEART  AND   LUNGS. 

wings  of  bees,  increasing  to  maximum  in  inspiration 
like  the  coming  waves  on  the  sea-shore,  and  decreasing 
in  expiration  as  they  recede.  If  the  breath  be  held,  this 
murmur  may  be  heard  without  admixture,  for  there 
can  then  be  no  bronchial  murmur.  The  sound  is  the 
susurrus  of  the  delicate  muscular  fibres  of  the  true 
respiratory  system,  contracting  and  relaxing  over  the 
dilating  and  resisting  residual  air.  If  the  breath  be 
held  after  a  full  inspiration,  the  murmur  will  be  at  its 
maximum  ;  if  it  be  held  after  expiration,  it  will  be  at  its 
minimum  fulness.  It  cannot  be  exaggerated,  as  has 
been  said  of  the  so-called  vesicular  murmur.  If  the 
true  respiratory  system  be  unduly  dilated,  it  loses  its 
power  to  contract  on  the  residual  air,  and  the  murmur 
wholly  ceases.  This  is  a  sign  of  emphysema,  and  is 
proof  of  the  muscular  cause  or  origin  of  the  sound 
which  may  return  again  after  rest. 

This  murmur  only  commences  to  be  developed  in  the 
child  at  eight  years  of  age,  becomes  recognizable  at 
twelve,  but  is  only  fully  developed  at  maturity.  A 
beginner  in  auscultation  may  recognize  true  respiratory 
murmur  in  a  good  subject  with  ease.  But,  when  the 
chest  has  lost  its  excellent  quality  as  an  acoustic  cham- 
ber by  physical  changes,  resulting  from  inflammation, 
or  when,  from  disease  of  the  lung  itself,  the  natural 
respiratory  murmur  has  been  altered  or  lost,  or  when 
the  chest,  although  in  its  natural  conditions,  may  be 
covered  by  thick  and  hardened  muscles,  the  trained, 
expert  ear  only  can  arrive  at  diagnostic  truth. 

Many  love  and  enjoy  music,  and  may  assist  in  pro- 
ducing it,  but  the  trained  expert  alone  can  lead  an 
orchestra,  and  harmonize  each  instrument  into  a  body 
of  perfect  song. 

These  facts,  instead  of  being  a  matter  of  discourage- 
mentj  should  induce  beginners  to  pursue  auscultation 


RESPiRATORV  Murmurs.  53 

With  untiring  assiduity,  knowing  that  the  eiid  will 
crown  them  as  masters  in  physical  diagnosis.  The 
ability  to  recognize  true  respiratory  murmur  under  any 
conditions,  to  analyze  its  quality,  and  measure  its 
power,  gives  its  possessor  the  means  of  knowing  even 
the  approach  of  that  most  insidious  disease,  phthisis, 
and  suggests  the  method  of  prevention.  The  true 
respiratory  system,  air-sacs,  alveoli,  nutrient  artery, 
ganglia  of  the  organic  nervous  system,  with  absorbents, 
etc.,  all  require  active  use  for  the  prevention  of  disease. 
Phthisis  does  not  begin  in  the  lower  part  of  the  lungs, 
which  are  constantly  and  actively  in  motion.  If  we 
insure  the  same  kind  of  exercise  in  the  upper  part,  we 
prevent  and  may  even  arrest  incipient  disease. 


S4  DISEASES  OF  THE  HEART  AND   LUNGS. 


IV. 

Plastic  Exudation  Within  the  Pleura. 

Dry  Pleurisy!^ 

It  is  the  known  experience  of  all  who  make  autop- 
sies that  thickened  pleura  and  pleuritic  adhesions,  the 
results  of  plastic  exudation,  are  of  frequent  occur- 
rence ;  and  yet  the  text-books  and  teachers  of  phys- 
ical diagnosis  give  us  no  signs  for  their  easy  and 
ready  recognition.  Practitioners  who  have  watched 
cases  all  through  a  whole  course  of  iUness,  ending 
fatally,  have  been  surprised  at  the  post-mortems  to  find 
abundant  evidence  of  plastic  exudation  within  the 
pleura,  although  none  had  been  suspected  during  life. 
It  seems  strange  that  medical  observers  have  been  con- 
tent with  the  absence  of  pathological  signs  which,  it 
would  seem,  should  be  so  obvious.  Standard  writers, 
however,  acknowledge  the  existence  of  intra-pleural 
noises.  Dr.  Walshe  arranges  and  classifies  them  (On 
Diseases  of  the  Lungs,  p.  113),  and  his  arrangement  is 
evidently  intended  to  cover  all  possible  intra-pleural 
sounds.  The  world  of  medicine  has  given  him  credit 
for  hardly  more  than  hypothetical  reasoning.  Re- 
cently, one  whose  experience  is  ample,  and  whose 
reputation  is  world-wide,  said  in  substance  that  it  was 
the  general  voice  of  the  profession  that  pleuritic  ad- 
hesions were  not  recognizable  by  signs,  and  that  if  they 
were  the  knowledge  would  be  of  no  practical  value. 

*  Read  before  the  N.  Y.  State  Medical  Society  at  Albany,  Feb.  5th, 

J873. 


PLASTIC  EXUDATION  WITHIN  THE  PLEUkA.         55 

This  undoubtedly  represents  the  accepted  views  of  the 
leaders  of  medical  thought.  In  regard  to  the  possibil- 
ity of  intra-pleural  noises,  Dr.  Stokes  says :  "  It  is  only 
when  the  surfaces  are  rendered  dry  by  an  arrest  of 
secretion,  or  roughened  by  the  effusion  of  lymph,  that 
their  motions  produce  sound  perceptible  to  the  ear." 
Dr.  Walshe  says, .  speaking  of  the  normal  conditions 
of  healthy  pleura :  ''  This  noiselessness  of  movement 
of  the  pleural  surfaces  upon  each  other  depends  at  once 
upon  their  perfect  smoothness  and  slight  humidity." 
The  silent  movement  of  the  healthy  pleura  upon  itself, 
and  the  rhonchoid  effect  of  plastic  exudation,  as  quoted 
from  Drs.  Walshe  and  Stokes,  and  which  are  self-evi- 
dent in  their  truthfulness,  seem  not  to  have  had  their 
proper  influence  upon  the  minds  of  medical  observers, 
and  this  may  be  the  reason  why  these  conditions  pro- 
ducing sound  have  been  so  generally  overlooked.  I 
believe  the  explanation  is  simply  that  it  is  because  the 
common  signs  belonging  to  plastic  exudation  within  the 
pleura  have  been  misinterpreted.  Mucous  rales  have 
been  considered,  and  truly,  as  being  caused  by  mucus 
moving  in  the  larger  bronchi,  and  also  the  so-called 
subcrepitant  or  SLjb-mucous  rales,  by  a  parity  of  reason- 
ing, have  been  described  as  being  formed  in  the  smaller 
tubes,  the  size  of  the  tube  proportioning  the  size  of  the 
rale.  From  the  first  postulate,  only  partially  true  in  it- 
self, all  the  succeeding  errors  have  arisen.  Mucous  rales 
may  be  formed  in  the  larger  bronchi ;  but  subcrepitant 
rales  cannot  occur  in  the  bronchioli.  I  think  I  have 
demonstrated  in  a  former  paper  {N.  Y.  Medical  Journal, 
May,  1872)  that  currents  of  air  in  the  true  respiratory 
system  are  impossible.  All  of  the  true  respiratory  sys- 
tem— that  is,  all  of  that  part  of  the  lungs  which  is 
beyond  the  third  and  fourth  divisions  of  the  bronchi — 
is  filled  persistently  by  the  residual  air.     No  motion 


$6  DISEASES    OF  THE   HEART  AND   LUNGS. 

can  ever  occur  there,  such  as  could  produce  friction 
murmurs.  There  is  no  motion  within  the  residual  air 
of  any  force  or  velocity  in  any  direction — no  movement 
at  all  except  the  molecular,  which  is  silent,  and  there  is 
no  need  of  any  other.  Therefore,  there  being  no  air 
movement,  there  can  be  no  subcrepitant  rales  formed 
within  the  true  respiratory  system,  for  their  mechanism 
in  the  bronchioli  becomes  a  physical  impossibility. 

Above  the  third  or  fourth  divisions  of  the  bronchi 
there  is  tidal  air,  producing  air  friction  murmur ;  and 
if  mucus  be  present  that  may  be  moved  along  with 
it,  rales  or  rhonchi  may  be  heard  at  the  chest  wall. 
Their  mechanism  places  them  at  different  distances 
from  the  ear,  and  the  same  rale  may  be  heard  at  several 
points,  a  fact  that  is  noted  by  that  delicate  organ 
with  marvellous  accuracy ;  whilst  plastic  rales  formed 
within  the  pleura  are  always  near  the  ear,  moving  wttk 
the  lung  and  parietes  in  expansion  and  contraction  of 
the  chest,  and  are  only  heard  over  the  site  of  their  oc- 
currence. The  true  mechanism  of  subcrepitant  rales  is 
always  intra-pleural,  and  depends  upon  the  presence  of 
exuded  lymph.  But  true  mucous  rales  may  be  tele- 
phoned into  the  chest-wall  at  long  distances  from  their 
occurrence,  and  yet  are  easily  recognized  as  such. 

Convincing  proof  of  the  correctness  of  these  novel 
positions  may  be  had  by  a  careful  comparison  of  clin- 
ical notes  of  the  szU  of  rales  with  their  post-mortem 
revelations.  In  my  own  experience,  both  in  hospital 
and  private  practice,  I  have  never  failed  to  find  the 
presence  of  plastic  exudation  after  death  as  cause  of  the 
rales  heard  during  life.  If  the  plastic  matter  be  of 
recent  formation,  the  signs  will  be  soft-tearing  rales, 
like  tearing  moist  flannel,  two  or  three  threads  at  a 
time.  The  rales  may  be  exceedingly  delicate,  and 
require  close  attention  and  acute  hearing  to  recognize 


PLASTIC   EXUDATION   WITHIN   THE   PLEURA.         57 

them,  and  a  corresponding  condition  of  the  exudation 
will  appear  at  the  autopsy.  Again,  the  adhesions  may 
be  months  or  years  old  and  the  rales  will  be  corre- 
spondingly hard  and  dry,  sometimes  creaking  like  new 
leather,  and  the  plastic  matter  will  be  found  after  death 
dense  and  strong,  like  bands  of  cartilage.  Dr.  Walshe 
is  in  error  when  he  says :  "  We  cannot  predicate  from 
the  character  of  the  friction  sound  the  state  of  the 
pleural  exudation,"  for,  availing  ourselves  of  the  real 
significance  of  subcrepitant  rales,  we  may  diagnosticate 
with  sufficient  accuracy  the  condition  of  the  exudation. 
The  character  of  the  rales  denotes  the  age  of  the  ad- 
hesions. When  tubercular  deposits  take  place  near  the 
surface,  pleuritic  exudation  may  be  an  accompani- 
ment. Consequently  these  rales,  although  intra-pleural, 
have  been  considered,  and  in  some  cases  the  diag- 
nosis would  be  correct,  as  evidence  of  softening  and 
breaking  down  of  tuberculous  masses,  or  caseous  de- 
generations. Still,  these  signs,  always  interpreted  as 
pulmonary,  may  lead  to  error  of  diagnosis,  for  the  rales 
may  disappear,  as  every  observer  knows,  and  no  lesion 
of  lung  structure  remain,  for  pleural  inflammation  may 
take  place,  even  at  the  apex,  and  no  tuberculosis  be 
present. 

Those  who  never  diagnosticate  phthisis  unless  they 
hear  moist  rales  will  mostly  make  their  diagnosis  too 
late  for  any  benefit  to  the  patient — sometimes,  possibly, 
diagnosticate  disease  which  does  not  exist.  Perhaps 
plastic  exudation  within  the  pleura  and  tuberculosis  in 
the  lung,  when  recent,  may  both  be  absorbed  and  no 
lesion  result.  Yet,  plastic  rales  heard  at  the  upper  part 
of  the  lung  are  a  grave  sign,  and  should  engage  our 
earnest  and  immediate  attention,  so  frequently  are 
they  the  precursors  of  disorganization.  They  may  be 
considered  a  warning  by  which,  if  heeded,  a  disastrous 


58  DISEASES  OF  THE  HEART  ANI)  LUNGS. 

result  may  be  avoided.  But  when  disintegration  of 
lung  does  take  place,  the  rales  remain  and  increase  in 
loudness  and  dryness,  and,  when  the  walls  of  the  cavity 
are  indurated,  they  are  reverberated  and  crackling  in 
character.  This  was  called  tubercular  crackling  by 
Laennec  and  his  followers,  although  the  mechanism 
was  acknowledged  to  be  a  mystery.  If,  however,  any 
one  will  carefully  note  the  site  of  these  signs  during 
life,  and  their  correspondence  with  pathological  condi- 
tions after  death,  he  can  hardly  fail  to  be  convinced 
that  the  cause  of  the  rales  is  in  the  stretching  of 
inter-pleural  adhesions  near  or  over  a  cavity.  But 
if  the  walls  of  the  cavity  are  soft  and  yielding,  and, 
more  so,  if  they  contain  fluid,  the  sounds  produced  by 
the  stretching  adhesions  will  be  liquid  in  character, 
like  gurgling,  but  may  be  distinguished  from  the  true 
by  being  persistent,  while  the  true  gurgling  disappears 
when  the  cavity  is  emptied. 

Dr.  Walshe  relates  a  case  (p.  ii6.  On  Diseases  of  the 
Lungs)  which  proves  that  these  crackling  rales  may  be 
formed  outside  of  the  lung.  He  says :  "  An  extremely 
abundant,  medium-sized  rhonchus  occurring  almost  in 
puffs,  and  having  the  liquid,  bubbling  character  in  a 
most  marked  manner,  was  day  after  day,  during  the 
week  previous  to  death,  detected  in  the  entire  height 
of  the  left  side  posteriorly.  The  explanation  of  the 
rhonchus  naturally  suggesting  itself  was  that  it  de- 
pended upon  oedema  of  the  pulmonary  tissue  generally. 
At  the  post-mortem  examination,  however,  I  found  this 
explanation  was  inadmissible,  for  the  thin  lamella  of 
tissue  between  the  cavity  and  the  surface  was  as  hard 
as  cartilage,  and  contained  not  a  particle  of  serosity ; 
nor  was  the  organ  in  any  part  distinctly  infiltrated  with 
fluid,  being  on  the  contrary  particularly  dry,  from  its 
excessive  induration."     He  afterward   says :    '^  Subse- 


PLASTIC   EXUDATION  WITHIN  THE  PLEURA.         59 

quent  experience  has  amply  proved  the  correctness  of 
this  explanation,  and  shown  that  moist  sounds,  rhon- 
choid  in  properties,  are  producible  whenever  adventi- 
tious tissue  within  the  pleura  is  infiltrated  with  serosity 
and  the  movements  of  the  chest  continue  free." 

Proof  that  these  crackling-  rales  are  formed  outside 
the  lung  is,  that  when  the  plastic  exudation  has  been  so 
abundant  as  to  bind  down  a  large  space  of  lung,  so  as 
to  prevent  all  motion  in  the  pleura,  there  will  be  no 
rales.  The  disintegrated  lung  underneath  being  in  the 
same  condition,  both  when  the  pleura  is  movable  and 
when  it  is  not,  the  rales  should  be  the  same  in  each 
were  they  formed  within  the  lung. 

The  following  cases  are  offered  as  proof  that  sub- 
crepitant  rales  always  have  an  intra-pleural  origin : 

Case  I. — Margaret  Simpson,  New  York,  21,  single. 
Examined  at  my  office,  Sept.  23d,  1870,  for  admission 
into  the  House  of  Rest  for  Consumptives,  at  Tremont, 
N.  Y.  Right  side,  clavicular  and  mammary  regions ; 
loss  of  true  respiratory  murmur ;  broncho  respiratory 
prolonged  in  expiration,  and  raised  in  pitch  in  inspira- 
tion. Dulness  with  raised  pitch  on  percussion.  Dry 
adhesion  rales,  subcrepitant  in  character,  at  the  lower 
portion  of  the  lung,  both  before  and  behind,  but  more 
extensively  behind.  Left  apex — a  large  cavity  recog- 
nized by  cavernous  respiration,  with  dry  crackling 
reverberations  in  the  cavity.  Dulness  and  raised  pitch 
over  the  whole  upper  region  of  the  left  lung,  with  sub- 
crepitant rales  at  the  lower  part,  before  and  behind. 
Died  October  15th,  1870.  Post-mortem  by  H.  M. 
Sprague,  M.D.,  physician  to  the  institution.  Large 
cavity  in  the  upper  part  of  the  left  lung,  and  caver- 
nules  below.  Cavernules  in  the  upper  part  of  the  right 
lung.  Both  lungs  completely  bound  to  the  chest  wall  with 
pleuritic  adhesions. 


6o  1)ISEASES   OF  THE   HEART  AND   LUKGS. 

Case  II. — Rebecca  Robinson,  born  in  Ireland,  ag6 
35.  Examined  at  my  office  October  29th,  1870,  for  ad- 
mission into  the  House  of  Rest,  etc.  Right  lung — evi- 
dence of  tuberculosis;  second  stage,  in  upper  part. 
Left  lung — large  cavity  in  the  upper  part;  signs  of 
pleuritic  adhesions  (subcrepitant  rales)  in  the  lower 
part  of  both  lungs — more  in  the  left  than  in  the  right. 
Post-mortem  examination  December  i8th,  1870,  by  H. 
M.  Sprague,  M.D.,  physician  to  the  institution.  Large 
cavity  found  in  the  left  lung,  smaller  in  the  right ;  both 
pleura  bound  firmly  to  the  chest  wall  by  adhesions. 

Case  III. — Mrs.  P.,  aged  60,  examined  by  H.  M. 
Sprague,  M.D.,  for  admission  to  the  House  of  Rest  for 
Consumptives,  Tremont,  N.  Y.,  November  25th,  1872. 
Respiratory  murmur  altered  at  the  left  apex;  almost 
entirely  absent.  The  so-called  subcrepitant  rhonchus 
heard  over  both  lungs,  anteriorly  and  posteriorly.  De- 
cember loth,  complained  of  having  taken  cold  ;  coughed 
rather  more  than  usual;  was  feverish.  The  pleuritic 
friction  rales  (subcrepitant)  much  more  marked  than 
before.  Died  the  next  day.  Autopsy  twenty-four 
hours  after  death.  Right  lung  tuberculous  ;  is  the  seat 
of  pneumonia ;  commencement  of  second  stage.  Pleura 
thickened  at  the  upper  part  from  plastic  exudation. 
Lung  bound  to  the  chest  wall  over  its  entire  surface.  Ad- 
hesions infiltrated  with  serosity.  Left  lung  bound  to  the 
chest  wall  firmly  in  every  part,  though  separated  from  it 
by  a  layer  of  serum.  Over  the  apex  the  pleura  thick- 
ened to  about  one  fourth  of  an  inch,  and  hard  as  leather. 
Left  lung  very  much  congested  at  apex.  Dilated  bron- 
chus of  the  size  of  the  little  finger.  The  inner  surface 
ragged  and  ulcerated,  and  the  walls  thickened  and 
fibrous.  About  half  a  pint  of  serum  remained  in  each 
pleural  cavity  after  removing  the  lungs. 

Case  IV. — W.  M ,  aged  35.    Admitted  January 


PLASTIC   EXUDATION  WITHIN   THE   PLEURA.         6l 

6th,  1873,  ^o  the  House  of  Rest  for  Consumptives.  Ex- 
amined by  H.  M.  Sprague,  M.D.  Cavity  in  the  left 
apex  and  subcrepitant  rales  heard  over  the  whole  of 
both  lungs.  On  the  day  of  admission,  complained  of 
having  taken  cold,  was  chilly  during  the  day  ;  two  sub- 
sequent days  remained  in  about  the  same  condition, 
but  grew  worse  and  died  January  9th,  the  third  day 
after  admission.  Autopsy  twenty-four  hours  after 
death.  Bot/i  lungs  botuid  down  firmly  to  the  chest  wall^ 
and  adhesions  infiltrated  with  serum.  About  half  a 
pint  of  serum  in  each  pleural  cavity,  after  removing  the 
lungs.  A  large  cavity  in  the  upper  lobe  of  the  left 
lung,  containing  a  small  half  ounce  of  purulent  matter. 
The  cavity  was  lined  with  a  diphtheritic  membrane, 
easily  removed.  The  pleura  over  the  left  apex  very 
much  thickened ;  lower  lobes  congested  and  studded 
with  grayish,  fibrous  nodules,  of  the  size  of  bird-shot — 
(tubercles  ?).  The  right  lung  was  the  seat  of  acute  pneu- 
monia. Middle  lobe,  near  the  root  of  the  lung,  con- 
tained a  few  of  the  same  fibrous  nodules,  which  were 
interspersed  with  caseous  nodules  of  the  size  of  a  pea. 

Evidently  the  post-mortem  revelations  in  Dr. Walshe's 
case  were  a  surprise,  so  contrary  were  they  to  the 
usual  interpretation  of  signs.  Still,  holding  to  the  pul- 
monary origin  of  subcrepitant  rales  generally,  he  gives 
the  following  directions  for  making  differential  diagno- 
ses !  "  The  crackling  form,  in  itself  indistinguishable 
from  some  conditions  of  subcrepitant  rhonchus,  may 
be  diagnosticated  by  the  existence  of  friction  sounds, 
constant  or  occasional,  and  by  its  being  unaffected  by 
coughing.  Mere  moisture  in  the  plastic  matter  within 
the  pleura  seems  enough  to  give  a  rhonchoid  character 
to  friction  sounds.''  I  am  quite  confident  that  if  Dr. 
Walshe  might  test  all  the  subcrepitant  rales  by  com- 
paring tbem  with  the  post-mortem  conditions^  as  he  did 


62  DISEASES   OF  THE   HEART  AND   LUNGS. 

in  the  case  of  crackling,  he  would  be  equally  convinced 
that  they  all  have  an  intra-pleural  origin.  Dr.  Sprague's 
cases  prove  not  only  that  the  crackling  rales,  but  also 
the  subcrepitant,  are  of  intra-pleural  origin.  They 
also  prove  that  sounds  that  have  been  dry  may  become 
liquid  in  character,  when  infiltrated  with  serosity  from 
accession  of  disease.  Old  adhesions,  when  the  patient 
is  well,  may  become  almost  silent,  and  escape  ordinary 
attention,  but  if  the  patient  take  cold  they  become 
again  loud  and  distinct.  The  soft-tearing  rales,  spoken 
of  before,  indicate  recent  exudation,  and  the  softer  and 
more  liquid  the  sound,  the  more  recent. 

Commencing  at  this  point  in  the  scale,  we  may  rise 
through  all  the  gradations  to  dry  crackling  and  creak- 
ing of  old  adhesions,  which  are  as  unyielding  as  carti- 
lage. The  age  of  the  exudation  may  thus  be  pretty  ac- 
curately determined,  and  the  knowledge  prove  of  great 
practical  value.  Recent  deposits  of  lymph  m.ay  be  en- 
tirely reabsorbed,  leaving  the  lung  free  in  its  movement 
afterward.  Long  observation  convinces  me  that  plas- 
tic exudation  and  reabsorption  (without  medicine)  are 
a  common  occurrence,  the  power  of  the  vigorous  life 
of  the  body  being  sufficient  to  remove  effusion  or  exu- 
dation within  the  cavities,  unaided.  But  if  the  power 
of  the  life,  the  organic  life,  be  not  sufficient,  aid  must 
be  given  by  the  intelligent  physician,  or  the  exudation 
remains,  doing  more  or  less  damage,  b}^  binding  the 
lung  more  or  less  firmly.  Unwise  intermeddling  is 
more  to  be  feared  even  than  unaided  and  insufficient 
organic  life,  because  it  reduces  still  farther  the  already 
weakened  vital  power.  As  such  unwise  intermeddling 
I  would  specify  long-continued  depressing  medical 
agents  and  confinement  in  impure  air. 

If  the  disease  be  mistaken  for  bronchitis,  which  is  not 
Vinusu9.1  when  recent,  ancj  if  the  patiept  be  kept  in  % 


PLASTIC  EXUDATION  WITHIN  THE  PLEURA.        63 

warm  room,  in  impure  air,  and  dosed  with  nauseating 
and  depressing-  expectorants,  the  vital  power  may  be  so 
depressed  as  to  be  unable  to  remove  the  exudation,  and 
a  crippling  of  the  lung  will  be  the  consequence.  In  all 
cases  assistance  will  be  most  efficacious  in  the  earliest 
stages ;  then,  if  ever,  antiplastic  remedies  are  service- 
able. In  extreme  cases,  those  of  exceptional  violence, 
or  when  the  amount  or  extent  of  exudation  is  excesssive, 
the  powerfully  sedative  action  of  calomel  may  abort 
the  disease  so  completely  that  not  a  vestige  of  it  will 
remain — this,  too,  without  any  draught  upon  the  life- 
power  of  the  individual.  Twenty,  thirty,  forty,  or  even 
sixty  grains,  placed  on  the  tongue,  may  be  necessary  to 
produce  this  sedative  action.  No  one  but  the  physician 
attending  can  judge  of  the  dose  proper  to  the  case. 
The  proper  action  of  the  calomel  will  simply  be  the  dis- 
appearance of  the  grave  signs  and  symptoms.  The 
heart's  action  will  be  more  regular,  fuller,  and  slower. 
The  plastic  exudation  will  rapidly  disappear  by  reab- 
sorption.  There  will  be  no  purging,  no  ptyalism,  and 
no  exhaustion  of  vital  power.  I  know  of  nothing  so 
satisfactory  in  medicine  as  the  proper  application  of 
this  powerful  remedy,  when  given  in  the  disease  need- 
ing it,  and  at  the  right  time.  The  dose  should  be  given 
so  as  not  to  be  repeated — strike  but  once — repeated 
blows  may  do  harm.  In  milder  forms  of  the  disease, 
alkalies,  especially  muriate  of  ammonia,  may  do  the 
work  safely,  but  more  slowly.  One  thing  should  not 
be  forgotten,  and  that  is  the  anti-plastic  effect  of  pure 
air  and  simple  food.  These  several  means,  adapted  to 
each  individual  case,  will  seldom  fail  to  cause  the  ab- 
sorption of  plastic  exudation  when  recent,  but  it  is 
almost  impossible,  if  not  quite  so,  to  hasten  absorption 
in  old  and  cartilaginous  adhesions.  The  most  that  can 
be  done  for  them  is  to  remedy  their  progressing  qon^ 


64  DISEASES   OF  THE  HEART  AND   LUNGS. 

traction,  and  obviate  their  depressing  and  tubercular 
tendencies.  This  may  be  done  by  systematically  ex- 
panding the  chest,  endeavoring  to  elongate  the  adhe- 
sions  and  to  increase  the  vital  capacity.  Recent  ad- 
hesions may  with  certainty  be  rendered  innocuous  by 
expanding  the  chest  even  though  they  be  not  immedi- 
ately reabsorbed. 

In  the  etiology  of  tuberculosis  writers  have  consid- 
ered every  other  cause  but  plastic  exudation.  This  has 
no  place.  But  I  firmly  believe  that  when  the  true  sig- 
nification of  subcrepitant  rales  shall  be  known  as  plas- 
tic rales,  all  will  agree  with  me  that  this  cause  is  far 
more  potential  than  all  the  rest. 

Professor  Austin  Flint,  St.,  in  a  late  able  paper  on 
etiology  of  Phthisis,  adverts  to  the  fact  which  Niemeyer 
and  his  followers  lay  so  much  stress  upon — that  in 
many  of  the  cases  of  phthisis  the  patients  date  the  com- 
mencement of  their  illness  from  a  cold.  Niemeyer 
claims  this  as  proof  of  the  catarrhal  origin  of  the 
disease.  Every  clinical  observer  must  have  been 
struck  w^ith  the  fact  that  some  patients  are  positive 
as  to  the  time  and  particulars  of  their  attack,  such  as 
irregular  chills,  dry  cough,  sometimes  accompanied 
with  viscid  expectoration,  etc.;  also,  that  others  are 
just  as  positive  that  their  decHne  commenced  without 
cough  or  other  occult  symptoms.  They  had  weari- 
ness, loss  of  appetite,  loss  of  flesh,  and  dyspepsia,  long 
before  the  cough  characteristic  of  their  disease  com- 
menced. If  we  take  pains  to  number  them,  we  shall 
find  that  there  are  about  two  thirds  who  6^aU  the  time 
of  their  commencing  illness,  to  one  third  who  cannot; 
and  that  this  is  about  the  proportion  of  plastic  exuda- 
tion preceding  and  accompanying  phthisis,  and  that  of 
idiopathic  tuberculosis.  In  a  paper  on  Pleuritis,  which 
I  had  the  honor  to  read  before  the  New  York  Academy 


PLASTIC  EXUDATION  WITHIN   THE  PLEURA.         65 

of  Medicine  three  or  four  years  ago,  I  expressed  the 
opinion  that  a  large  majority  of  the  cases  of  phthisis 
which  had  been  under  my  care,  at  the  class  of  chest 
diseases  at  the  Demilt  Dispensary,  gave  evidence  by 
physical  signs,  frequently  confirmed  by  the  history, 
that  the  disease  had  commenced  with  pleurisy — mean- 
ing plastic  adhesions.  I  could  not  have  been  clear  in 
my  language,  for  I  was  generally  misunderstood. 
Nearly  every  one  who  discussed  my  paper  considered 
effusion  of  serum  as  a  necessary  accompaniment  of  pleu- 
risy ;  consequently  my  conclusions  were  disputed.  To 
make  this  matter  clear,  I  will  now  state,  that  I  did  not, 
nor  do  I  now,  assert  that  I  have  any  evidence  that 
pleurisy  with  effusion  has  a  tendency  to  end  in  phthisis. 
On  the  contrary,  I  wish  to  repeat  what  I  said  then, 
that  the  effusion  is  conservative,  preventing  the  evil 
tendencies  of  a  lung  crippled  by  adhesions,  for  the  effu- 
sion separates  the  pleura  till  the  danger  is  past. 

Cases  of  phthisis  may  and  do  follow  effusion  when 
not  removed  in  due  time,  but  they  are  rare,  and  I  fully 
agree  with  those  gentlemen  who  so  stoutly  opposed 
views  I  did  not  hold.  But  1  did  hold,  and  do  now, 
with  more  conviction  than  ever,  that  plastic  exudation, 
crippling  the  lung,  has  a  depressing  tendency  upon  the 
organic  life  of  the  body,  and  is  very  frequently  followed 
b}^  phthisis. 

The  intelligent  observer  who,  having  the  evidence  of 
exudation  rales  before  him,  shall  follow  the  cases  to 
the  dead-house,  will  have  proof  that  adhesions  have  a 
powerful  influence  in  precipitating  phthisis.  Plastic 
exudation  within  the  pleura  obeys  the  same  law  which 
it  does  in  other  parts  of  the  body.  It  continues  to  con- 
tract some  time  after  its  exudation.  Consequently  the 
lung  becomes  more  and  more  crippled,  and  it  must 
either  decline  into  desuetude,  provoking  tuberculosis. 


66  DISEASES   OF   THE   HEART   AND    LUNGS. 

or  in  its  efforts  to  free  itself  become  emphysematous. 
It  is  the  Laocoon  of  animal  life  struggling  within  the 
tightening  folds  of  the  plastic  python.  Emphysema  is 
the  opposite  of  tuberculosis,  and  systematic  forcible  ex- 
pansion of  the  crippled  lung  may  produce  temporary 
emphysema,  effectually  preventing  phthisis. 

My  private  note-book  shows  that  more  than  two 
thirds  of  the  cases  of  phthisis  examined  in  my  office 
have  had  plastic  exudation  within  the  pleura,  which 
must  have  influenced  its  commencement  or  progress. 
Sometimes  phthisis  follows  immediately,  or  rather  be- 
gins with  the  exudation,  and  then  it  is  frequently  ac- 
companied by  hsemoptysis,  which  should  not  be  inter- 
fered with ;  it  is  nature's  self-preserving  act.  In  the 
early  stages  of  fibroid  phthisis  haemoptysis  may  occur 
from  time  to  time,  after  each  new  exudation  of  plastic 
matter;  but  eventually  the  bleeding  ceases  from  ex- 
tension of  fibroid  in  the  lung,  and  to  great  emaciation 
from  the  diminished  quantity  of  circulating  blood. 

Haemoptysis  in  fibroid  phthisis  is  an  encouraging 
sign,  for  it  is  evidence  that  nature  has  not  given  up  the 
fight. 

The  following  cases,  taken  from  many  others,  are 
given  to  illustrate  the  depressing  effects  of  plastic  exu- 
dation within  the  pleura,  and  also  its  tubercular  tenden- 
cies, and  that  these  tendencies  are  preventable : 

Case  I. — A  gentleman  about  •  32  years  old  had 
haemoptysis  in  1861,  and  the  left  lung  remained  with 
physical  signs  of  arrested  phthisis.  In  October,  1872, 
while  in  the  country,  he  had  hemorrhages,  lasting  about 
one  week.  He  was  said  to  have  had  pneumonia  also. 
In  December  he  returned  to  the  city,  and  examination 
detected  plastic  exudation  over  the  whole  of  the  right 
pleura,  and  that  extensive  disorganization  had  taken 
place  in  the  right  lung.     Plastic  exudation,  no  doubt, 


PLASTIC  EXUDATION  WITHIN  THE  PLEURA.        (i^ 

from  these  signs,  took  place  at  the  time  of  the  hsemop- 
tysis  in  October,  more  than  two  months  before.  Dis- 
integration of  the  lung  must  have  commenced  immedi- 
ately after  the  plastic  exudation,  for  he  was  examined  a 
few  days  before  going  into  the  country,  and  at  that 
time  the  right  lung  was  free  from  disease.  It  is  possi- 
ble that  a  powerfully  sedative  dose  of  calomel,  placed 
on  his  tongue  at  the  time  of  the  haemoptysis,  might 
have  relieved  the  crippled  lung,  and  have  saved  the 
patient's  life. 

Case  II. — In  the  early  part  of  July,  1872,  a  profes- 
sional gentleman  was  found  to  have  plastic  exudation  in 
the  left  pleura,  extending  from  below  up  to  the  inter- 
nal angle  of  the  scapula.  The  subcrepitant  rales  were 
abundant,  but  confined  to  these  limits.  True  respira- 
tory murmur  could  be  heard  over  the  rest  of  both 
lungs.  He  had  been  complaining  for  a  few  weeks  of 
irregular  chills  and  cough,  but  thought  these  symptoms 
due  to  malaria.  About  the  first  week  in  August  he  was 
again  examined.  The  adhesion  rales  remained  as  at 
the  first  examination,  but  both  lungs  had  lost  expan- 
sion, and  also  true  respiratory  murmur. 

He  went  to  the  country  and  returned  to  the  city 
again  in  October,  being  absent  about  nine  weeks.  It 
was  found  that  he  had  a  large  cavity  near  the  root  of 
the  lung.  The  right  lung  was  without  expansion,  and 
without  true  respiratory  murmur,  but  there  was  no 
consolidation.  Plastic  exudation  ensued  in  the  right 
lung  in  December,  precipitating  the  end. 

In  this  case  the  plastic  exudation  preceded  the 
phthisis  a  definite  period.  There  were  no  signs  of 
tubercle  in  July.  There  were  signs  of  tubercle  in  both 
lungs  in  August,  and  rapid  disorganization  of  the  left 
lung  followed. 

Case   III. — Mrs. had  plastic    exudation  about 


68  DISEASES   OF  THE   HEART  AND   LUNGS. 

three  years  ago,  and  adhesions  remained  in  the  right 
pleura  at  the  lower  part.  She  had  been  examined  by 
several  physicians,  who  had  heard  the  adhesion  rales, 
and  also  the  true  respiratory  murmur  in  both  lungs. 
In  August,  1872,  she  had  chills  and  cough,  followed  by 
loss  of  flesh  and  strength,  and  some  spitting  of  blood. 
In  October  she  was  carefully  examined,  and  it  was 
found  she  had  lost  chest  expansion  and  true  respiratory 
murmur,  and  that  there  were  soft  subcrepitant  rales 
over  both  lungs,  though  not  abundant. 

She  was  directed  to  systematically  expand  the  lungs, 
to  be  much  in  the  open  air,  to  take  plentifully  of  milk 
and  farinaceous  food ;  cod-liver  oil ;  also  muriate  of 
ammonia,  quinine,  and  iron.  She  followed  the  advice 
thoroughly,  and  in  four  weeks'  time  she  was  again  ex- 
amined, when  there  was  better  expansion  of  the  chest, 
and  true  respiratory  murmur  could  again  be  heard. 
In  December  she  had  recovered  her  usual  health. 

I  cannot  doubt  that  in  this  case  phthisis  was  pre- 
vented. 

Case  IV.* — February  19th,  1873.  I.  H ,  a  square- 
built,  heavy-chested  man,  came  to  my  office  for  exami- 
nation ;  he  had  been  spitting  blood  at  times  during  the 
eight  days  previous.  At  two  or  three  different  times 
he  spat  up  about  half  a  pint  of  blood,  and  at  others  a 
smaller  amount.  His  wife  had  been  ill  several  months 
with  consumption,  and  he  had  been  much  with  her,  and 
was  frightened  at  the  idea  that  he  might  have  caught 
the  disease.  He  was  very  pale,  and  had  a  coated 
tongue.  Examination  detected  abundant  plastic  exuda- 
tion rales  in  the  lower  part  of  the  right  pleura,  forming 
a  band  about  three  inches  broad,  extending  from  the 
vertebra  around  to  the  junction   of  the  ribs  with  the 

*  Added  since  the  paper  was  read  at  Albany. 


PLASTIC   EXUDATION   WITHIN   THE  PLEURA.         69 

cartilages.  The  lungs  were  slightly  emphysematous, 
but  otherwise  healthy.  Believing  this  to  be  a  case 
which  warranted  an  attempt  at  perfect  relief  by  forcing 
absorption  of  the  exuded  matter,  I  wrote  for  one 
scruple  of  calomel  and  ten  grains  of  sugar,  and  directed 
him  to  place  the  powder  on  the  back  part  of  his  tongue 
that  evening.  February  22d  he  called  again  to  say 
the  hasmoptysis  had  ceased,  that  he  had  had  two  or 
three  full  passages  from  the  bowels,  and  that  he  felt 
well.  Examination  showed  the  lungs  to  be  free  in 
movement  and  without  rales  of  any  kind. 

This  case  may  be  considered  as  evidence  :  ist.  That 
the  sedative  action  of  calomel  may  cause  rapid  absorp- 
tion of  plastic  exudation  within  the  pleura ;  2d.  That 
intra-pleural  plastic  exudation  may  cause  hsemoptysis, 
with  great  depressing  effect  upon  the  ganglionic  life ; 
and  that  the  liability  to  tuberculosis  from  these  condi- 
tions, especially  when  there  is  phthisical  proclivity,  is 
obvious. 

I  could  adduce  many  other  cases  illustrating  all  these 
points,  were  it  necessary,  and  time  sufficient,  but  con- 
tent myself  with  believing  that  the  means  of  diagnosis 
are  within  the  available  reach  of  all,  and  that  proofs 
will  constantly  occur  convincing  to  the  most  skeptical. 

I  will  therefore  merely  restate  the  points  which  I 
consider  to  be  the  most  important  in  connection  with 
the  subject. 

1st.  Adhesions  and  thickened  pleura  are  among  the 
most  frequent  pathological  results  discovered  at  au- 
topsies. 

2d.  That  generally  they  are  not  known  during  life, 
as  the  sounds  they  make  are  considered  pulmonary, 
and  errors  of  diagnosis  and  errors  of  treatment  are  the 
consequence. 

3d.  Plastic  exudation   within  the  pleura  is  even  a 


70  DISEASES    OF   THE   HEART   AND   LUNGS. 

more  frequent  accident  than  can  be  determined  at  au- 
topsies ;  reabsorption  so  speedily  taking  place  that  no 
adhesions  remain. 

4th.  Binding  adhesions  prevent  expansion  of  the 
chest,  and  consequently  of  the  true  respiratory  system, 
hurry  the  heart-beat,  derange  the  digestive  organs,  pre- 
vent proper  assimilation  of  food,  depress  the  vital 
force,  and,  unless  emphysema  results,  precipitate 
phthisis  pulmonalis. 

5th.  About  two  thirds  of  the  cases  of  phthisis  seen  in 
clinical  practice  commence  with  or  after  adhesions  ; 
that  haemoptysis  frequently  is  coexistent,  and  that  such 
cases  are  more  remediable,  as  a  rule,  than  others. 

6th.  That  the  remedial  means  are  systematic  but  not 
forcible  expansion  of  the  lungs,  change  of  air,  a  proper 
supply  of  food  that  may  be  easily  assimilated  ;  and  that 
medicines,  when  used,  should  be  antiplastic  and  tonic, 
sustaining  the  organic  life. 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  7I 


V. 

Physical  Signs   of   Interpleural   Pathological 

Processes.* 

In  health  the  pleurae  are  smooth,  opposing-  surfaces, 
free  in  motion,  and  lubricated  by  their  natural  secre- 
tion. They  cover  the  inner  costal  wall,  the  outer  sur- 
face of  the  pericardium,  nearly  the  entire  upper  sur- 
face of  the  diaphragm,  and  all  the  surfaces  of  the  lungs. 
They  help  to  form  the  mediastinum,  and  surround  the 
origin  of  the  great  vessels  and  of  the  air-passages.  In 
short,  they  line  the  great  acoustic  chamber  of  the 
chest,  and  cover  the  sound-producing  organs  which  it 
contains.  The  constant  motion  of  these  organs  gives 
voice  to  their  action,  and  breathes  into  the  ear  of  the 
auscultator  an  harmonious  idyl  of  health,  or  whispers 
and  mutters  of  the  discordances  of  disease. 

The  acoustic  properties  of  the  normal  chest  are  so 
perfect  that  the  most  delicate  signs,  such  as  true  respi- 
ratory murmur  or  aortic  regurgitation,  are  delivered 
through  its  walls  to  the  ear  without  loss  or  change. 
The  healthy  pleurae  are  no  obstacle  to  the  free  passage 
of  sound  and  at  the  same  time  are  no  cause  of  sound  in 
themselves.  It  is  like  looking  into  an  open  room  filled 
with  light. 

But  at  the  first  trace  of  an  inflammatory  process  they 
cease  to  be  silent  themselves,  and  modify  or  prevent 
sound  passing  through  them.  It  is  like  looking  into  a 
room  filled  with  cloud,  through  obscured  glass ;  noth- 
ing is  clearly  seen. 

*  The  Medical  Record,  May  35,  1878. 


72  DISEASES   OF  THE   HEART  AND   LUNGS. 

The  pleurae  are  prone  to  diseased  change.  Mental 
depression,  physical  exhaustion,  or  sudden  alternations 
of  temperature,  may  cause  hypersemia,  and  plastic  exu- 
dation is  then  likely  to  follow.  It  is  a  vital  process, 
but  indicates  a  diseased  condition  of  organic  life.  It 
occurs  in  cellular  tissue  and  on  serous  surfaces — very 
frequently  on  the  pleural.  Comparatively  few  autopsies 
are  made  without  discovering  more  or  less  of  inter- 
pleural thickening  and  adhesions. 

"  Physicians  of  old  did  not  regard  them  as  preter- 
natural ;  nor  do  many  at  the  present  day  consider  them 
as  necessarily  connected  with  inflammation.  This 
opinion  is  founded  upon  the  fact  of  these  adhesions 
being  met  with  in  individuals  not  known  to  have  suf- 
fered from  any  inflammatory  affection  of  the  chest. 
But  until  satisfactorily  traced  to  some  other  cause,  it 
would  appear  more  proper  to  refer  these  exclusively  to 
an  inflammatory  origin."  (Hasse's  Path.  Anat.  p.  182.) 
The  process  may  be  summarized  as  follows : 

First,  local  vital  exhaustion,  vaso-motor  paresis, 
stasis,  hyperaemia  ;  then  the  white  globules,  "■  the  wan- 
dering amoeba,"  pass  through  the  meshes  of  the  walls 
of  the  capillaries,  and,  unless  immediately  absorbed, 
organize  and  result  in  adhesions  and  thickened  pleura. 
All  this  may  take  place  without  rise  of  temperature. 

More  or  less  of  impaired  health  follows,  with  obscure 
symptoms,  periodicity  in  rise  of  temperature.  New 
exudations  take  place  from  time  to  time,  crippling  the 
respiratory  organs,  and  seriously  implicating  the  circu- 
lation, until  the  patient  dies,  worn  out,  with  resulting 
complications  of  all  the  vital  organs. 

These  serious  pathological  results  have  hitherto  been 
unrecognized,  except  in  part  and  inadequately,  during 
life  by  physical  signs.  In  March,  1870,  I  had  the  honor 
of  reading  a  paper  before  the  New  York  Academy  of 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  73 

Medicine  on  Pleuritis.  In  the  discussion  which  fol- 
lowed, Dr  Flint,  Sr.,  remarked  that  "  He  was  not  aware 
that  there  are  any  distinctive  physical  signs  of  per- 
manent adhesions  that  can  be  depended  upon  as  path- 
ognomonic." This  was  undoubtedly  then,  and  perhaps 
is  largely  yet,  the  received  opinion  of  the  profession, 
Dr.  Walshe  alone,  among  the  authorities,  interpreting 
certain  physical  signs  as  of  adhesions  and  pleural 
thickening.  I  had  adopted  from  my  teachers  the  gen- 
erally received  opinions ;  but  considerable  clinical  ex- 
perience, obtained  in  the  class  of  chest  diseases  at 
Demilt  Dispensary,  caused  me  to  question  their  truth. 
There  were  repeated  occurrences  Avhich  seemed  to  me 
to  furnish  incontrovertible  proof  that  many  of  the  phys- 
ical signs  of  the  chest  had  been  misinterpreted.  But 
even  yet  I  was  not  prepared  to  give  up  my  precon- 
ceived idea  of  the  local  origin  of  mucous  and  crepitant 
rales. 

But  about  ten  years  since,  a  patient  came  into  St. 
Luke's  Hospital,  from  Bellevue,  with  a  disputed  diag- 
nosis. The  case  had  been  afifirmed  to  be  one  of  simple 
hydrothorax,  and  then  again  to  be  hydropneumo- 
thorax.  Both  opinions  were  correct.  Upon  examina- 
tion it  was  found  on  the  right  side  that  there  was  dul- 
ness  and  loss  of  respiratory  murmur  up  to  about  three 
inches  above  the  diaphragm  ;  and  bordering  the  upper 
line  of  dulness,  and  encircling  the  lung,  there  was  crepi- 
tus and  subcrepitus.  It  was  simple  circumscribed  hy- 
drothorax. But  upon  directing  the  patient  to  take  a 
forced  inspiration  and  hold  the  breath,  air  was  forced 
into  the  artificial  chamber  made  by  the  adhesions,  and 
the  case  was  immediately  changed  into  one  hydropneu- 
mothorax.  In  a  little  while  the  air  escaped,  and  the 
case  was  as  at  first.  To  account  for  this  it  was  neces- 
sary to   suppose  that  there  was  a  valvular  opening, 


74  DISEASES   OF  THE   HEART  AND   LUNGS. 

through  which  air  could  come  from  from  the  lung. 
The  fluid  was  removed  by  intercostal  incision,  and  the 
case  kept  under  observation.  After  a  time  the  left 
side  showed  signs  of  disease.  There  were  mucous 
rales  and  gurgles,  and  progressive  loss  of  weight  and 
strength.  The  case  was  frequently  referred  to  as  an 
example  of  tubercular  phthisis.  The  rales  were  of  vari- 
ous sizes,  and  were  considered  as  signs  of  tubercular 
infiltration  and  honey-combed  cavernules. 

At  the  autopsy  the  circumscribing  adhesions,  with 
the  valvular  opening  in  the  lung,  were  found  on  the 
right  side,  as  was  expected  ;  but,  to  our  astonishment, 
there  was  no  structural  change  in  the  left  lung.  Be- 
tween the  pleural  surfaces,  however,  there  was  a  large 
amount  of  plastic  exudation,  together  with  a  small 
quantity  of  viscid  fluid  ;  at  many  points  also  there  were 
firm  adhesions.  These  interpleural  deposits  were  evi- 
dently the  only  source  of  the  sounds  I  had  misinter- 
preted as  signs  of  the  tubercle  and  tuberculous  cavities 
of  small  size.  I  was  convinced  that  the  same  condi- 
tions had  frequently  deceived  me  in  other  cases. 

Since  then  I  have,  in  repeated  instances,  carefully 
noted  and  recorded  the  locality  of  rales  and  their  dis- 
tinctive characteristics,  for  the  purpose  of  testing  them 
in  relation  to  pathological  conditions,  to  be  revealed 
by  autopsies.  In  no  instance  have  I  have  found  them 
to  disagree  with  the  interpretation  that  their  cause  lay 
in  an  interpleural  process. 

The  following  case  is  one  in  which  old,  firm,  and 
close  interpleural  adhesions  drew  the  heart  upward, 
and  caused  murmurs  by  displacements. 

Case  I. — J.  S.  T.,  an  honored  member  of  our  pro- 
fession, called  on  me  in  company  with  Dr.  Otis,  in  the 
spring  of  1876.  About  seven  years  before  he  had 
pleuro-pneumonia,  and  several  times  since   slight  at- 


INTERPLEURAL  PATHOLOGICAL   PROCESSES.  75 

tacks  of  pleurisy.  He  was  short  of  breath,  and  dis- 
tressed after  exertion,  or  on  going  up  stairs ;  he  had  at 
times  severe  pain  in  the  region  of  the  heart  like  angina. 
Aneurism  of  the  aorta  and  valvular  disease  of  the  heart 
were  feared. 

Examination  discovered  some  dulness  at  the  sum- 
mits of  the  lungs.  There  was  flat  wooden  percussion 
note  over  both.  There  was  very  little'  expansion,  and 
the  movement  of  the  chest  was  restricted.  There  were 
a  few  rales  of  various  sizes  over  the  greater  part  of 
the  chest.  At  the  lower  angle  of  the  scapula  of  the 
left  side  there  were  no  rales,  nor  any  movement  of 
the  lung  even  in  forced  inspiration,  but  coughing 
produced  short  fine  crepitus  immediately  under  the 
ear. 

True-respiratory  murmur  was  feeble  generally,  but 
absent  at  the  apices  of  both  lungs.  The  apex  beat  of 
the  heart  was  between  the  fourth  and  fifth  ribs,  a  little 
to  the  left,  and  there  was  a  systolic  murmur. 

Diagnosis  :  old  extensive  adhesions  over  both  lungs  ; 
no  disease  of  the  heart  or  of  the  arteries. 

On  the  1 2th  of  October,  1876,  he  received  a  wound, 
to  the  right  of  the  sternum  over  the  auricle,  by  a  piece 
of  a  brass  tube  imbedding  itself  in  the  lung  and  the 
pericardium.  Pericarditis  and  pneumonia  followed, 
and  he  died  on  the  20th. 

The  da}^  before  his  death,  and  probably  for  some 
time  previously,  there  were  abundant  soft  "  mucous" 
rales.  These  were  diagnosticated  also  as  interpleural. 
The  autopsy  revealed  pericarditis  and  pneumonia  of 
the  whole  of  the  right  lung,  which  was  consolidated — 
the  mould  of  the  ribs  remaining  on  its  surface  after  it 
was  removed  from  the  chest. 

Hence,  no  air  could  have  entered  the  lung.  New 
exudation  had  taken  place  among  the  old  adhesions. 


"J^y  DISEASES   OF  THE   HEART  AND   LUNGS. 

and  efforts  at  respiration  moved  the  chest-wall  over 
the  solid  lung,  thus  producing  "  mucous  rales." 

Case  II. — Is  kindly  given  in  a  letter  from  Prof.  J. 
L.  Little,  and  is  equally  decisive :  "  My  dear  Doctor, 
I  cheerfully  comply  with  your  request  that  I  would 
Jurnish  you  with  the  points  in  the  history  of  a  case 
bearing  on  the  subject  of  your  paper.  I  was  called  to 
see  a  patient  in  consultation  v/ith  Dr.  Roediger,  on 
August  14th  last,  and  found  a  man  about  forty-five 
years  of  age,  who  was  suffering  slight  pain  in  the  left 
side — no  cough,  no  expectoration,  high  temperature 
and  frequent  feeble  pulse.  On  auscultation,  subcrepi- 
tant  rales  could  be  heard  on  the  posterior  surface  of 
the  left  side  of  the  chest.  These  were  more  abundant 
and  of  a  much  coarser  quality  at  the  upper  part  of  the 
lung,  although  more  or  less  subcrepitation  could  be 
heard  from  apex  to  base.  On  percussion,  flatness  was 
discovered  over  the  entire  upper  portion  of  lung ;  the 
lower  showed  but  slight  dulness.  I  saw  the  patient  in 
consultation  on  the  17th,  i8th,  and  19th.  At  the  last 
visit,  eighteen  hours  before  death,  subcrepitation  was 
heard,  as  at  first  examination.  On  forced  expansion 
after  coughing,  the  rales  were  markedly  increased  in 
number,  and  seemed  to  be  very  near  the  ear.  Patient 
died  August  20th.  Autopsy  by  Drs.  Roediger  and 
Nesbitt.  Left  lung  was  found  solid  with  pneumonia, 
except  the  lower  part  of  the  inferior  lobe.  The  upper 
was  in  a  state  of  gray  hepatization,  the  middle  red. 
The  lower  part  was  very  much  congested,  but  crepi- 
tated on  pressure.  The  pleurae  were  covered  with 
plastic  exudation,  but  the  adhesions  were  slight.  The 
false  membrane  covering  the  upper  third  of  the  lung 
was  three  or  four  millimetres  in  thickness.  The  lower 
portion  was  covered  with  only  a  thin  layer.  In  this 
case.  Doctor,  the  rales  heard  over  the  posterior  surface 


INTERPLEURAL  PATHOLOGICAL  PROCESSES.         77 

of  the  chest  were  without  doubt  due  to  the  exudation 
on  the  surface  of  the  pleurae.  No  air  could  possibly 
have  entered  the  upper  or  middle  portions  of  the  lung 
for  some  days  before  death. 

^'  Yours  truly,  J.  L.  Little." 

These  two  cases  are  evidence  of  a  positive  character 
verified  by  post-mortem  examination. 

Case  III.* — C.  M ,  saleswoman,  eighteen  years 

old,  came  to  my  office  for  examination  on  the  14th  of 
September,  1877.  Percussion-note  dull  over  lower  part 
of  left  lung  in  front  and  up  to  the  middle  of  interscap- 
ular space  behind.  There  was  bronchophony,  bronchial 
breathing  with  subcrepitant  rales.  At  the  lower  por- 
tion of  the  lung  in  front  was  Ji7te  crepitus.  As  the  lung 
was  consolidated  by  pneumonia  no  air  could  enter 
it,  and  consequently  the  rales  must  have  been  in  the 
pleurae.  This  evidence  is  further  corroborated  by  the 
fact  that  since  then  the  pneumonia  has  cleared  up, 
resonance  returning,  but  subcrepitant  rales  remain  in 
place  of  the  crepitant. 

These  three  cases  may  be  regarded  not  as  unusual, 
but  as  typical,  and  they  furnish  proof:  ist.  That  mu- 
cous, 2d,  that  subcrepitant,  3d,  that  crepitant  rales  may 
all  have  their  local  origin  within  the  pleurae. 

It  is  difficult  to  overcome  preconceived  opinions 
even  with  evidence  perfectly  conclusive  to  an  un- 
prejudiced mind.  Still  the  facts,  which  I  have  given, 
and  others  which  I  shall  further  relate,  must  commend 
the  subject  to  all  candid  observers. 

Has  the  generally  received  opinion  that  all  large. 


*This  case  is  of  a  class  common  to  all  practitioners,  and  is  introduced 
as  such.  It  has  no  novelty,  but  after  the  post-mortem  evidence  of  Cases 
I.  and  II.  the  clinical  evidence  of  consolidated  lung  becomes  proof  of 
the  impossibility  of  the  rales  being  interpulmonary. 


78  DISEASES   OF  THE   HEART  AND   LUNGS. 

soft,  moist  rales  are  caused  by  bursting  bubbles  in  the 
bronchi  ever  been  put  to  the  test  of  careful  experi- 
ment ?  On  the  contrary,  is  it  not  the  general  experi- 
ence that  abundant  mucous  rales  may  exist  without 
expectoration,  and  profuse  expectoration  without  rales, 
or  only  with  such  as  are  distant  from  the  ear,  and 
which  disappear  upon  expectoration  ?  Has  not  the 
received  opinion  that  all  the  rales  of  whatever  size, 
liquidity  or  dryness,  have  their  origin  in  the  lungs, 
and  that  the  size  of  the  bronchia  determines  the  size 
of  the  rale,  been  adopted  by  pupil  from  teacher,  from 
the  time  of  Laennec  to  the  present,  without  regard  to 
the  obvious  fact  that  the  large  rales  are  most  frequently 
heard  over  portions  of  the  chest  where  the  bronchial 
tubes  are  very  small,  and  the  small  rales  where  they  are 
large  ? 

Early  auscultators  explained  the  respiratory  mur- 
murs of  health,  as  well  as  the  rhonchi  of  disease,  as 
being  formed  by  the  air  passing  through  the  bronchi 
into  the  vesicles  and  out  again;  that  the  friction  of 
this  body  of  air  in  motion  caused  vesicular  murmur 
and  bronchial  breathing ;  and  that  should  mucus  col- 
lect, it  would  be  moved  along  bursting  bubbles  in  its 
way — crepitant,  subcrepitant  and  mucous,  according  to 
the  size  of  the  rale.  Later,  another  theory  was  pro- 
posed, and  by  many  adopted,  which  still  regarded  the 
size  of  the  tube  as  governing  the  size  of  the  rales.  Ac- 
cording to  this  theory,  the  tube  being  lined  with  adhe- 
sive mucus,  collapsed  after  expiration,  and  the  sides 
cohering,  inspiration  would  again  force  them  apart, 
causing  rales.  Neither  theory  recognizes  obstruction 
to  the  free  passage  of  air  into  the  air-sacs  and  out 
again,  yet  the  residual  air  certainly  occupies  the  true 
respiratory  system  and  does  not  admit  air  moving  in  a 
body.     The  tidal  air  physiologists  estimate  to  be  about 


INTERPLEURAL  PATHOLOGICAL  PROCESSES.  79 

one-tenth  part  of  that  in  the  lungs.  So  that  after 
expiration  there  still  remains  nine  tenths,  occupying- 
the  true  respiratory  system.  This  is  the  residual  air. 
When  inspiration  again  takes  place  the  column  of  m- 
moving  air  passes  in  a  body  to  about  the  third  or  fourth 
division  of  the  bronchia,  and  can  go  no  further,  but 
mixes  with  the  residual  air,  obeying  the  law  of  the  dif- 
fusion of  gases. 

It  is  evident,  in  view  of  these  facts,  that  both  theories 
are  impossible.  The  existence  of  so  large  a  mass  of 
residual  air  in  the  air-cells  and  smaller  bronchial  tubes, 
and  also  the  existence  of  consolidated  lung  tissue  (in 
which  solid  material  fills  the  spaces  previously  oc- 
cupied by  the  residual  air),  both  show  conclusively 
that  all  rales  called  crepitant  and  subcrepitant,  when 
heard  under  these  conditions  are  not  intrapulmonary, 
and  that  mucous  rales,  when  not  clearly  traceable  to 
the  large  bronchi,  are  also  not  intrabronchial,  and  con- 
sequently all  rales  not  clearly  traceable  to  the  larger 
air-passages  are  interpleural. 

Mucus  in  the  upper  bronchia  may  cause  mucous  rales, 
which  are  intermittent.  The  mucus  accumulates,  the 
rales  are  heard ;  it  is  expectorated,  and  they  are  gone. 
In  suffocative  catarrh,  and  in  approaching  dissolution, 
the  rales  are  continuous. 

It  would  seem  possible  that  fibroid  lung  could  also 
produce  subcrepitation  in  cases  where  the  lung  is  ad- 
herent to  the  chest-wall.     But  of  this  I  have  no  proof. 

The  following  case  of  fibroid  phthisis  was  cha;*ac- 
terized  by  a  variety  of  rales  and  rhonchi,  which  would 
deceive  any  one  who  did  not  recognize  them  as  signs 
of  an  interpleural  pathological  process.  They  were 
very  suggestive  of  cavernulous  phthisis  and  of  disease 
of  the  heart. 

Case  IV. — W.  S ,  about  sixty  years  of  age,  mer- 


80  DISEASES   OF  THE   HEART  AND   LUNGS. 

chant,  while  in  Scotland  in  1874,  had  pneumonia,  and 
since  then  had  had  frequent  colds,  causing  short,  spas- 
modic cough,  with  gradual  increasing  dyspnoea.  He 
came  under  my  care  early  in  1876.  His  breath  was 
short  and  hurried.  There  were  rales  over  both  lungs ; 
in  some  places  coarse  and  rattling,  and  in  others  smaller, 
even  fine  crepitus.  At  the  lower  part  of  the  right  in- 
terscapular space,  and  below  the  scapula,  they  were 
coarse,  moist,  and  gurgling.  Under  the  right  axilla 
down  to  the  diaphragm  there  were  creaking  as  well  as 
dry  rales.  Under  the  Ifeft  clavicle  there  were  mucous 
gurgles,  and  under  the  left  scapula  there  were  fine 
crepitant  and  subcrepitant  dry  rales.  There  was  gen- 
eral flatness  under  percussion,  with  raised  pitch  over 
most  of  the  chest.  There  was  an  audible  systolic  mur- 
mur at  the  apex  beat.  The  impulse  was  felt  almost  as 
high  as  the  nipple,  and  there  was  also  impulse  in  the 
second  interspace. 

The  diagnosis  was  extensive  plastic  exudation  be- 
tween the  pleural  surfaces,  forming  adhesions  which 
had  drawn  the  lungs  and  heart  upward.  The  dyspnoea 
and  cardiac  complications  were  the  consequence  of 
these  changes,  and  there  was  no  other  serious  lesion. 
At  first  he  improved  under  treatment,  and  gained  more 
than  an  inch  in  chest  expansion,  and  was  able  to  get 
about  with  much  less  difficulty  than  before  treatment, 
but  in  May  an  attack  of  pneumonia  increased  the 
amount  of  plastic  exudation,  and  he  lost  more  by  sub- 
sequent contraction  than  he  had  previously  gained  in 
expansion.  During  the  summer,  in  the  country,  he  was 
under  the  immediate  care  of  Dr.  Ely,  of  Newburg.  He 
was  able  at  times  to  ride  out,  but  new  attacks  of  exu- 
dation lessened  his  vital  capacity,  and  finally,  after 
another  "  cold,"  he  had  increased  disease,  from  which 
he  died  Oct.  8,  1876. 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  8 1 

Autopsy  by  Prof.  Delafield,  Oct.  loth.  Present,  Drs. 
Jones,  Dudley,  G.  A.  Peters,  Ely,  and  Learning. — 
"  Body  much  emaciated,  cadaverous  discoloration 
already  evident  on  abdomen.  Pericardium  contains  a 
little  serum.  Apex  of  heart  on  level  with  lower  edge 
of  fourth  rib — distant  three  and  one-fourth  inches  from 
median  line.  Upper  border  of  heart  on  level  with  lower 
edge  of  first  rib.  Long  axis  of  heart  turned  somewhat 
in  vertical  direction. 

"  Lungs. — Left  side,  very  extensive  old  adhesions 
covering  the  entire  lung.  Left  lung,  upper  lobe  at  the 
apex,  some  bands  and  patches  of  pigmental  fibrous  tis- 
sue. Lower  lobe,  lower  third,  bands  of  new  fibrous 
tissue  and  red  hepatization— the  red  hepatization  is 
recent.  Right  lung,  old  adhesions  over  entire  lung. 
Upper  lobe,  the  same  diffuse  fibrous  tissue,  but  more 
abundant. 

"  Heart. — Right  ventricle  contains  large  yellow  post- 
mortem clot.  Pulmonary  valves  a  little  thickened  at 
their  attached  edges.  Ventricle  a  little  dilated,  walls 
of  normal  thickness,  tricuspid  valve  a  little  thickened. 

"  Left  ventricle  contains  a  small  post-mortem  clot. 
Cavity  rather  diminished.     Walls  normal  thickness. 

"  Aortic  valves  somewhat  atheromatous  and  stiffened, 
and  on  ventricular  aspect  of  one  leaf  a  small  fibrous 
projection.  Mitral  valve  a  little  thickened  and  athero- 
matous. 

"  Kidneys. — Normal  size,  capsule  not  adherent,  sur- 
face smooth,  cortex  normal  in  appearance  and  thick- 
ness.    Aorta  markedly  atheromatous." 

(Signed)  Francis  Delafield. 

This  instructive  case  illustrates  the  diagnostic  value 
of  correctly  locating  the  site  of  rales  and  rhonchi — as 
inter-bronchial  or  inter-pulmonary  they  mean  tubercular 
cavities — tubercular  phthisis,  as  interpleural  they  indi- 


82  DISEASES   OF   THE   HEART  AND   LUNGS. 

cate  old  cellular  adhesion  with  fluid  in  the  interstices, 
extending  into  the  lungs — fibroid  phthisis. 

The  first  step  in  these  complicated  pathological 
changes  was  plastic  exudation  between  the  pleurae, 
which,  becorAing  organized,  formed  adhesions,  and  these 
in  turn  gave  rise  to  all  the  subsequent  diseased  condi- 
tions in  the  lungs  and  of  the  heart. 

Case  V. — M.  M.,  get.  40,  single.  Saw  her  in  consul- 
tation with  Dr.  E.  D.  Hudson,  Jr.,  September  7,  1877, 
morning.  Heart  and  great  vessels  gave  no  evidence  of 
disease.  Pulse  and  cardiac  sounds  were  feeble  and  fre- 
quent, suggesting  fatty  degeneration.  Chest  expansion 
was  not  more  than  half  an  inch  ;  respiratory  murmur 
very  faint ;  very  little  air  entering  the  lungs.  No  dis- 
ease of  the  lungs  or  pleurse  was  discovered.  But  there 
was  evident  obstruction  in  the  air-passages,  the  patient 
gasping  for  breath.  Lung  free  from  dulness.  Highest 
local  pitch  in  respiration  traced  to  the  larynx,  and  the 
obstruction  was  believed  to  be  at  this  point. 

The  laryngoscope,  in  the  skilled  hands  of  Dr.  Lef- 
ferts,  proved  this  opinion  to  be  erroneous. 

Evening. — Consultation  with  Drs.  Hudson  and  Lin- 
coln. There  was  now  found,  at  the  summit  of  the  left 
lung,  perceptible  dulness  and  flatness  under  percussion, 
and  soft  tearing  rales  in  auscultation,  conditions  which 
had  developed  since  morning.  Respiration  was  more 
difficult,  and  during  the  examination  became  so  great 
that  unconsciousness  resulted.  No  time  was  to  be  lost, 
and  Dr.  Lincoln  performed  tracheotomy,  and  the  ob- 
struction was  found  to  be  below  the  trachea.  No  evi- 
dence of  aneurism  was  discovered.  Dr.  G.  F.  Shrady 
informs  me  that  he  refused  to  give  this  patient  ether 
for  an  operation  previously,  because  he  suspected  aneu- 
rism.    Death  occurred  early  on  the  morning  of  the  8th. 

Autopsy,  afternoon  of  the  same  day,  by  Dr.  Hudson, 


INTERPLEURAL  PATHOLOGICAL   PROCESSES.  83 

in  the  presence  of  Drs.  Lefferts,  Hitchcock,  and  Kemp. 
"  Cause  of  death,  aneurism  at  the  posterior  surface  of 
arch  of  aorta  descending.  Trachea  and  bronchia  atro- 
phied by  the  pressure  of  the  tumor.  Heart  fatty,  lungs 
reduced  in  volume,  but  normal  otherwise.  At  the  left 
apex  the  opposed  pleural  surfaces  were  agglutinated, 
the  soft  adhesions  offering  slight  resistance  in  separat- 
ing. Several  older,  organized  but  elastic  adhesions 
spanned  the  left  pleural  cavity."  (Notes  of  the  autopsy 
kindly  furnished  by  Dr.  Hudson.) 

This  case  is  evidence  that  plastic  exudation  may  be 
diagnosticated  as  soon  as  it  takes  place.  There  were 
neither  rales  nor  dulness  in  the  morning,  but  there  were 
both  in  the  evening,  and  fresh  plastic  material  was  found 
at  the  autopsy.  Hasse  says  :  "  The  first  appearance  of 
inflammation  of  the  pleura  consists  in  a  congested  state 
of  its  blood-vessels,  which  are  seen  congregated  here 
and  there,  in  dense  though  delicate  nets,  beneath  the 
still  transparent  membrane.  At  certain  points  the 
bright-red  color  deepens  and  becomes  more  equalized  ; 
these  points  are  somewhat  prominent,  and,  though  scat- 
tered at  first,  presently  crowd  together  and  get  encom- 
passed with  a  progressively  enlarging  zone  of  gorged 
blood-vessels.  At  the  same  time  patches  and  streaks 
are  observed  either  darker  than  the  rest,  and  not  unlike 
little  ecchymoses,  or  else  of  a  pale  red  hue,  as  if  from 
imbibition.  The  pleura  now  speedily  loses  its  smooth- 
ness and  polish,  becoming  dull  and  looking,  as  Laennec 
expresses  it,  as  if  daubed  over  with  a  paint-brush.  This 
redness  gradually  spreads  until  in  most  instances  the 
whole,  says  '  Gendrin,'  becomes  uniform. 

"  The  first  rudiments  of  an  adventitious  membrane 
now  become  perceptible,  the  spots  originally  reddened, 
and  that  chiefly  by  repletion  of  the  vessels,  presenting 
little  dull  white  or  yellowish  points  which  rise  above 


84  DISEASES   OF  THE   HEART   AND   LUNGS. 

the  serous  surface  in  the  shape  of  flat  granules,  and 
ultimately  eoalesce."     (Hasse's  Path.Anat.,  p.  i  33.) 

All  of  the  pathological  changes  described  above, 
from  the  first  congested  blood-vessels  in  nets  to  the  final 
covering  of  the  whole  pleura  with  lymph,  produce  the 
following  signs  :  First,  muffling  ;  second,  alterations  of 
the  respiratory  murmur  ;  and  then,  finally,  rales  and 
rhonchi,  indicating  exudation  of  plastic  material.  Every 
step  of  the  pathological  process  is  characterized  by  its 
appropriate  physical  signs. 

Experience  and  a  nice  education  of  the  ear  make  an 
early  diagnosis  easy  and  certain,  and  enable  the  practi- 
tioner to  use  remedies  which,  if  employed  in  good  sea- 
son, remove  the  disability  and  the  danger. 

Case  VI. — (Plastic  signs  removed  by  hygiene.) — F. 
J.,  about  26  years  of  age,  while  at  business  in  Wall 
Street,  in  1874,  suddenly  began  to  raise  blood,  and  came 
immediately  to  my  office.  There  was  an  area  over  the 
right  scapula,  where  soft  tearing  rales  could  be  heard, 
and  there  was  also  flatness  under  percussion.  He  was 
advised  to  take  a  walking  expedition  of  two  or  three 
weeks'  duration.  This  he  did,  and  returned  in  health, 
not  a  vestige  of  the  plastic  rales  remaining  ;  nor  has  he 
had  any  return  of  chest  signs  or  symptoms  since. 

It  is  possible  that  had  he  remained  at  his  exhausting 
business  under  all  the  depressing  influences  which  had 
produced  their  conditions,  his  lower  vitality  would 
have  been  still  farther  depressed,  and  his  case  would 
have  resulted  in  phthisis,  as  many  others  have  done — so 
important  is  it  to  connect  physical  signs  correctly  with 
their  true  pathology. 

Plastic  exudation  upon  the  pulmonary  pleural  surface 
has  the  immediate  effect  of  obstructing  the  capillary 
circulation  in  that  part  of  the  true  respiratory  system 
which  subtends  the  deposit.     If  it  is  not  quickly  reab- 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  85 

sorbed  it  becomes  organized,  and  contracts,  causing 
still  greater  obstruction.  Hasmoptysis  frequently  re- 
sults— it  may  be  immediately,  but  in  most  cases  not  un- 
til after  two  or  three  weeks,  or  even  longer. 

The  reason  of  this  is  evident,  if  we  consider  the  mi- 
nute anatomy  of  the  circulation  of  the  true  respiratory 
system.  The  nutrient  arteries  of  the  lungs  are  derived 
principally  from  the  bronchial,  and  differ  from  all 
others  in  the  body,  in  the  fact  that  they  have  no  return- 
ing veins  ;  no  vencB  comites.  The  nutrient  capillaries 
after  performing  their  special  function,  anastomose  with 
the  radicles  of  the  pulmonary  vein,  and  their  blocd  is 
reaerated  even  while  performing  its  office,  and  hence, 
notwithstanding  this  apparent  anomaly,  arterial  blood 
is  alone  forced  into  the  left  heart. 

Consequently  obstruction  to  the  nutrient  capillaries 
throws  their  blood  back  upon  the  bronchial  arteries, 
which  might  seriously  interfere  with  the  circulation, 
except  for  a  provision  of  nature,  by  which  mucus  is 
exuded  copiously  through  the  mucous  membrane 
(bronchorrhoea),  or  perhaps  blood  (bronchorrhagia). 
So  that  either  may  be  an  important  symptom  of  plas- 
tic exudation,  and  if  carefully  sought  for,  the  plastic 
rales  will  be  found. 

Case  VII. — G.  B.,  a  distinguished  surgeon,  April  i, 
1876,  had  pneumonic  sputa;  pulse  100,  temperature 
100°.  Had  some  oppression  in  breating,  but  no  pain. 
Auscultation  discovered  no  rales  on  either  side.  True 
respiratory  murmur  was  everywhere  good,  except  over 
a  part  of  the  middle  lobe  of  the  right  lung — a  space 
about  as  large  as  the  palm  of  the  hand — where  there 
were  also  perceptible  dulness  and  raised  pitch.  Diag- 
nosis: Centric  pneumonia  of  the  middle  lobe  of  the 
right  lung.  The  next  day  the  pulse  was  70  and  the 
temperature  97°.     Sputa  the  same  as  the  day  before, 


86  DISEASES   OF  THE   HEART  AND   LUNGS. 

and  so  it  remained  on  the  3d  and  on  the  4th.  Subse- 
quently the  temperature  was  as  low  as  93°. 

On  the  night  of  the  5th  of  April  he  suffered  great 
dyspnoea,  and  auscultation  found  abundant  rales  of 
crepitant  and  subcrepitant  size,  covering  that  part  of 
the  middle  lobe  of  the  right  lung,  posteriorly,  over 
which  true  respiratory  murmur  was  absent  at  the  first 
examination  on  the  ist  of  April.  The  centric  pneu- 
monia had  extended  to  the  pleural  surface,  exudation 
had  joined  the  pleurse  together,  and  crepitant  rale  and 
bronchial  breathing  were  plainly  heard.  The  dyspnoea 
from  which  he  suffered  was  the  consequence  of  these 
adhesions. 

He  gradually  improved  until  the  27th  of  April,  when 
he  went  to  Fortress  Monroe  for  change  of  air.  Shortly 
afterwards  he  had  a  return  of  dyspnoea,  and  as  it  in- 
creased he  came  home  on  the  5th  of  May.  He  now 
had  moist  tearing  rales  low  down  on  the  left  side.  The 
heart  was  restrained  in  motion,  and  the  first  sound  was 
altered  in  character.  These  signs  indicated  fresh  plas- 
tic exudation  in  the  left  pleural  cavity,  as  a  result  of 
which  attachments  had  formed  with  the  pericardial  sac, 
and  with  the  lung,  altering  the  heart  sounds  and  giving 
an  intraventricular  murmur  at  the  apex.  During  the 
rest  of  the  month  of  May  and  of  June  following  there 
was  progressive  plastic  exudation,  invading  more  and 
more  of  the  pleura,  and  causing  distressing  dyspnoea. 

From  the  first  there  had  been  albumen  in  the  urine, 
with  some  casts.  But  in  July  there  Avas  notable  im- 
provement in  all  the  symptoms  ;  yet  the  rales  remained, 
and  exercise  was  exhausting.  In  the  latter  part  of  Au- 
gust he  returned  to  the  city  and  attended  to  some  pro- 
fessional duties  ;  was,  out  riding  daily,  and  visited  the 
hospitals.  But  late  in  the  autumn  one  chilling  day,  at 
the  hospital,  he  took  cold,  and  was  again  obliged  to 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  8/ 

keep  his  room.  There  was  another  advance  in  plastic 
exudation  in  the  left  side  ;  the  heart  was  more  restrained 
by  tightening  bands  of  adhesions  ;  there  was  general 
and  gradual  failure  in  health  until  the  6th  of  March, 
1877,  when  he  died. 

Autopsy  by  Dr.  Abbe. — "March  7,  1867 — Pleura: 
Each  cavity  contained  about  a  pint  of  clear  serum. 

"  Right  lung,  bound  by  old  plastic  adhesions  over  pec- 
toral and  inframammary  regions  and  to  the  pericar- 
dium ;  latterly  over  entire  axillary  region,  and  some- 
what below,  though  not  to  the  diaphragm.  Posteriorly 
along  spine  up  to  the  summit  of  the  lung,  where  the 
apex  was  completely  adherent. 

"  Left  lung, — Apex  adherent  and  firm,  thence  extend- 
ing along  the  spine  two  thirds  downwards  to  base  of 
lung ;  also  bound  at  upper  part  of  subscapular  region. 
Three  or  four  fine  bands  of  recent  plastic  extended 
from  pericardium  to  left  lung.  The  lungs  were  not 
diseased. 

"  Liver  somewhat  contracted  and  fatty.  Gall-bladder 
contained  perhaps  a  dozen  small  concretions  not  larger 
than  mustard  seeds. 

"  Spleen  somewhat  hard  and  fibrous,  tightly  adherent 
to  extreme  of  left  lobe  of  liver  by  old  and  thick  adhe- 
sions ;  also  adherent  to  peritoneal  wall,  to  the  omentum, 
and  to  a  little  of  the  intestines. 

'■'■  Kidneys. — Both  somewhat  contracted,  the  right 
much  more  than  the  left,  weighing  about  three  ounces ; 
both  somewhat  cirrhotic  and  granular,  and  containing 
numerous  small  cysts,  varying  from  the  size  of  a  small 
pea  to  that  of  a  bean  ;  both  congested. 

'•'■Heart  considerably  enlarged;  valves  ample,  but 
somewhat  thickened  (especially  on  the  left,  by  athero- 
matous changes,  fatty,  etc.),  beginning  atheroma  of  the 
aorta,  though  without  calcareous  plates. 


88  DISEASES   OF   THE   HEART  AND   LUNGS. 

**  Intestines  and  bladder  normal.  Brain  not  examined.** 
(Signed)        Robert  Abbe,  M.D. 

About  two  years  before  his  last  illness  he  had  an  at- 
tack of  erysipelas,  and  at  that  time  careful  examination 
revealed  no  sign  of  kidney  disease. 

When  first  seen  on  that  first  day  of  April,  1876,  there, 
were  no  signs  of  chest  disease,  except  slight  dulness  on 
percussion  and  the  loss  of  true  respiratory  murmur 
over  a  space  about  three  inches  in  diameter,  over  the 
back  part  of  the  middle  portion  of  the  right  lung. 
There  were  no  rales  nor  rhonchi  until  the  night  of  the 
fifth,  when  subcrepitant  and  crepitant  rales  appeared 
exactly  in  the  place  where  the  loss  of  true  respiratory 
murmur  had  first  been  observed.  After  this  they  were 
never  absent,  but  gradually  extended  until  they  covered 
both  lungs,  becoming  firmer  and  dryer  as  they  grew 
older. 

It  would  seem  that  lowered  vitality  had  placed  the 
capillaries  of  all  the  organs  in  a  state  of  paresis  and 
stasis,  whence  resulted  plastic  exudations — a  general 
breaking  down,  in  which  all  the  vital  organs  were  suf- 
ferers. 

Case  VIII. — (Notes  and  autopsy  by  Dr.  Stedman,  of 
House  Staff.) — "  M.  A.  S.,  seamstress,  admitted  to  St. 
Luke's  Hospital,  September  29,  1877.  Has  been  feeling 
ill  since  last  spring ;  has  had  cough ;  lost  flesh  and  ap- 
petite. The  patient  is  not  complaining  much  of  her 
chest,  but  comes  to  be  treated  for  intermittent.  She 
had  a  chill  on  the  morning  of  admission. 

"  Oct.  loth. — Has  had  a  chill  every  other  day  since 
admission.  Examination  of  chest  to-day  shows  that 
the  right  lung  is  free  in  movement  in  front  without 
rales,  but  that  there  are  some  rales  and  signs  of  thick- 
ened pleura  in  the  lower  part  of  this  side  behind.  Over 
the  left  lung  there  are  plastic  exudation  rales,  both  in 


INTERPLEURAL  PATHOLOGICAL   PROCESSES.  89 

front  and  behind.  Closer  adhesions  (fine  dry  rales)  be- 
low. Soft  rales  are  heard  in  the  upper  part,  but  they 
grow  harsher  downwards. 

"Oct.  22d. — Patient  has  had  no  chill  since  the  nth. 
At  nine  o'clock  this  evening  was  seized  with  hsemop- 
t3^sis  and  died  from  suffocation  before  any  aid  could  be 
given. 

"Oct.  24th. — Autopsy, — Right  lung  free  from  adhe- 
sions, except  at  lower  part,  behind.  Left  lung  bound 
to  the  chest  loosely  above,  more  firmly  below,  both  an- 
teriorly and  posteriorly.  Lung  filled  with  tubercles 
(caseous  concretions),  and  two  newly-formed  cavities, 
one  at  the  apex  and  the  other  at  the  middle  of  the 
upper  lobe. 

"  Into  this  latter  the  hemorrhage  had  taken  place 
from  an  eroded  vessel  the  size  of  a  crow-quill.  The 
bronchial  tubes  and  trachea  were  filled  with  blood. 
The  pericardial  and  pulmonary  pleura  were  firmly  ad- 
herent." 

The  points  of  interest  in  this  case  are:  i.  That  the 
interpretation  of  rales  as  denoting  an  interpleural  pa- 
thological process  was  correct. 

2.  That  caseous  deposits  in  small  scattered  masses 
may  fill  the  lung  without  being  detected  when  loose  ad- 
hesions shut  off  sound,  and  especially  when  the  true 
respiratory  murmur  is  feeble  or  absent. 

When  the  adhesions  are  firm  and  close,  sound  is  more 
directly  transmitted,  and  the  pathological  condition  of 
the  lung  may  be  more  easily  diagnosticated. 

3.  Fatal  hemorrhage  nearly  always  takes  place  sud- 
denly. A  softened  caseous  deposit  opens  into  a  bron- 
chus, and  at  the  same  time  erodes  a  blood-vessel  of 
some  size,  and  the  cavity  and  air-passages  are  imme- 
diately filled  with  blood,  and  the  patient  dies  as  by 
drowning. 


90  DISEASES   OF  THE   HEART   AND   LUNGS. 

Case  IX. — Pietro  Angelo,  set.  29,  Italy,  sailor,  ad- 
mitted to  St.  Luke's  Hospital,  May  i,  1877.  Had  artic- 
ular rheumatism,  for  which  he  was  successfully  treated 
with  salicylic  acid. 

June  loth. — Was  examined  with  the  expectation  of 
discovering  heart  lesions,  but  none  were  found ;  but 
there  was  signs  of  a  cavity  under  the  clavicle  of  the  left 
side.  Dry,  crackling  rales  were  found  over  the  left 
side,  and  in  the  region  of  the  heart  there  were  a  few 
rales  synchronous  with  the  heart-beat. 

Diagnosis. — Cavity  in  clavicular  region ;  old  adhe- 
sions over  whole  of  lung;  also  adhesions  between  the 
left  lung  and  the  pericardium.  Right  lung  free.  Pa- 
tient says  he  has  had  cough  for  some  time ;  complains 
of  no  pain,  and  did  not  think  he  had  any  disease  of  the 
chest. 

June  20th. — Patient  has  had  high  temperature  for  a 
day  or  two.  Examination  shows  abundant  soft  rales  in 
left  side,  large  and  small,  which  have  supplanted  the 
dry  rales  synchronous  with  the  heart's  motion. 

July  1st. — Patient  is  losing  flesh,  and  has  cough  with 
purulent  expectoration.  A  creaking  sound  is  heard  in 
the  region  of  the  heart,  synchronous  with  the  move- 
ments of  the  lungs  and  also  with  those  of  the  heart. 

Aug.  I  St. — Patient  failing;  considerable  expectora- 
tion, difficult  breathing,  hectic,  and  night-sweats. 

Sept.  3d. — Patient  complains  of  severe  pain  in  the 
right  side,  with  increased  dyspnoea.  Examination 
showed  moist,  tearing  rales  with  each  respiration  over 
right  lung,  the  one  hitherto  healthy.  On  the  left  side, 
in  front,  a  harsh  leathery  creak  is  heard,  but  no  rales 
synchronous  with  the  heart's  motion,  although  it  is  evi- 
dently restrained  ;  behind,  low  down,  there  are  numer- 
ous dry  subcrepitant  rales. 

Sept.  14th. — Died  at  5  P.  M, 


INTERPLEURAL   PATHOLOGICAL  PROCESSES.  9I 

Post-mortem^  Sept.  15th,  seventeen  hours  after  death. 
— "  Right  side  of  chest :  adhesions  over  whole  lung,  at- 
taching it  to  the  chest-wall,  but  soft  and  easily  separa- 
ted by  the  finger.  Left  side  :  the  lung  is  firmly  adher- 
ent to  the  chest-wall  and  also  to  the  pericardial  sac,  and 
could  be  separated  from  them  only  by  dissection. 
There  is  a  dry  tubercular  or  caseous  deposit  in  upper 
part  of  right  lung,  and  a  good-sized  cavity  in  upper 
part  of  the  left." 

(Signed)     T.  L.  Stedman,  M.D. 

It  will  be  seen  that  the  soft  adhesions  easily  detached 
in  the  right  pleural  cavity  agree  in  age  entirely  with 
the  appearance  of  moist  rales  of  Sept.  3d.  The  evi- 
dence is  decisive,  for  there  was  no  disease  of  the  lung 
nor  of  the  bronchia  to  cause  rale.  The  dry  harsh  rales 
of  the  left  side  also  agree  in  physical  conditions  (firmly 
adherent,  could  only  be  separated  by  dissection)  in  age, 
with  the  time  they  had  been  under  observation.  In 
both  sides  the  age  of  the  adhesions  was  correctly  diag- 
nosticated by  the  physical  signs.  Another  very  inter- 
esting fact,  and  of  practical  importance,  is  brought  clear- 
ly into  the  light,  vizo,  that  of  diagnosticating  adhesions 
between  the  pericardium  and  the  lung  and  be- 
tween the  pericardium  and  the  mediastinum,  by  the 
sign  of  rales  synchronous  with  the  heart's  motion. 
These  signs  are  not  uncommon,  and  are  additional  evi- 
dence of  the  interpleural  origin  of  all  rales.  Cog-wheel 
respiration  is  due  to  adhesions  betAveen  the  lung  and 
the  pericardium.  If  the  patient  takes  a  full  inspiration, 
the  broncho-respiratory  murmur  will  be  interrupted  by 
each  beat  of  the  heart  during  the  inspiration,  and  also 
during  the  time  while  the  breath  is  held.  The  motion 
of  the  heart  bringing  into  sudden  tension  the  adhesions 
stops  the  respiratory  sound  for  an  instant  at  each  beat. 
If  the  attention  is  fixed  upon  the  recurrence  of  these 


92  DISEASES   OF  THE   HEART   AND   LUNGS. 

interruptions  it  will  sometimes  be  possible  to  analyze 
this  short  rhonchus,  and  to  distinctly  recognize  that  it 
is  made  up  of  fine  crepitant  rales.  Occasionally  it  is 
heard  to  the  right  of  the  sternum  near  the  cartilage  of 
the  sixth  rib,  and  at  the  diastole  of  the  heart,  simulating 
aortic  regurgitant  murmur,  except  that  it  is  not  heard 
to  the  left  of  the  sternum.  In  this  position  its  crepitant 
quality  may  be  very  manifest.  The  adhesions  are 
between  the  pericardium  covering  the  right  auricle  and 
the  right  lung.  When  the  pericardium  is  attached  to 
the  mediastinum,  a  systolic  murmur  of  the  heart  may 
result.  So  that  interpleural  signs  falsely  interpreted 
lead  to  incorrect  diagnosis  as  regards  diseases  both  of 
the  heart  and  of  the  lungs.  Many  other  cases  are  re- 
corded which  furnish  equally  strong  proof  of  the  cor- 
rectness of  the  views  here  advocated. 

The  late  Dr.  Sprague,  of  Fordham,  at  the  House  of 
Rest  for  Consumptives,  made  about  forty  autopsies,  in 
which  the  evidences  were  conclusive  that  the  localities 
of  rales  were  the  sites  of  adhesions ;  that  the  localities 
of  adhesions,  unless  so  tight  as  to  prevent  all  motion, 
were  always  the  sites  of  rales.  Dr.  Sprague's  eminent 
ability  and  painstaking  assiduity  render  his  observations 
of  great  value.  I  am  fully  persuaded  that  if  those  hav- 
ing opportunities  will  note  the  locality  of  rales  for  the 
purpose  of  verifying  at  autopsies  the  presence  of  adhe- 
sions, it  will  become  impossible  to  doubt  the  mechanism 
of  their  interpleural  production. 

What  diagnostic  interpulmonary  signs  have  we  re- 
maining, if  all  the  rales  and  rhonchi  hitherto  considered 
as  evidence  of  pueumonia,  bronchitis,  capillary  bron- 
chitis, oedema  of  the  lung,  tuberculosis,  cavities,  etc.,  are 
to  be  interpreted  as  of  interpleural  origin  ?  Need  we 
be  anxious  about  the  consistency  of  Nature  ?  May  we 
not  leave  that  to  her,  resting  assured  that  as  our  knowl- 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  93 

edge  is  increased  we  will  become  more  consistent 
observers,  and  see  that  she  is  always  right  ?  It  is  all- 
important  for  correct  diagnosis,  and  in  the  treatment 
and  management  of  disease,  that  the  physical  signs 
should  indicate  the  pathological  conditions.  The  very 
frequent  mistake  of  treating  bronchorrhcea  for  bronchi- 
tis, and  ignoring  the  interpleural,  pathological  cause, 
until  the  lung  is  irretrievably  crippled,  will  be  avoided. 
If  we  recognize  the  earliest  signs  of  plastic  exudation 
between  the  pleurae  we  are  enabled  in  all  ordinary 
cases  to  promote  its  entire  absorption.  But  if  the  favor- 
able time  is  allowed  to  pass  the  exuded  plastic  material 
becomes  organized,  and  even,  if  but  of  limited  extent, 
may  be  from  time  to  time  the  focus  of  renewed  exuda- 
tions, until  the  whole  lung  is  bound  to  the  chest-wall. 
Fibrous  bands  also  extending  through  the  pulmonary 
tissues  contract,  as  they  grow  older,  and  finally  result 
in  the  miserable  conditions  of  fibroid  phthisis. 

Diseases  of  the  lungs  and  bronchi  are  manifested  by 
their  own  signs,  after  excluding  those  which  we  have 
demonstrated  to  be  interpleural.  In  so  doing  the  gain 
is  in  greater  accuracy  in  diagnosis,  and  in  greater  dis- 
crimination in  the  value  of  signs.  The  crepitant  rale, 
although  having  its  mechanism  within  the  pleural  cav- 
ity, is  yet  a  yaluable  sign  of  pneumonia,  or  of  phthisis, 
as  it  so  often  accompanies  these  diseases  ;  but  it  is  not 
pathognomonic.  It  may  exist  in  the  absence  of  both, 
and  either  may  be  present  without  crepitant  rales. 
Centric  disease,  without  cavities  and  without  interpleu- 
ral adhesions,  is  without  rales  or  rhonchi.  Yet  there 
is  an  area  of  dulness  and  of  absence  of  true  respiratory 
murmur,  exactly  agreeing  with  the  locality  of  the  dis- 
ease, which,  with  the  rational  signs  of  temperature, 
pulse,  and  sputa,  render  its  detection  sufficiently  clear 
to  avoid  mistakes  in  treatment.     Depending  upon  crep- 


94  DISEASES   OF  THE   HEART   AND   LUNGS. 

itant  rales  as  pathognomonic  has  many  times  delayed 
prompt  treatment,  and  has  resulted  perhaps  in  the  loss 
of  the  patient.  Convincing  demonstrations  alone 
changed  my  views  as  to  their  intrapulmonary  mechan- 
ism. In  pneumonia  the  exudation  of  plastic  matter  in- 
to the  connective  tissue  of  the  true  respiratory  system 
is  an  early  phenomenon.  1  formerly  believed  that  the 
stiffened  air-sacs,  yielding  reluctantly  to  the  expansive 
force  of  inspiration,  must  separate  the  newly-exuded 
fibrine  in  the  cellular  tissue,  thus  giving  rise  to  multitu- 
dinous rales. 

Dr.  Walshe  once  proposed  the  same  theory,  which 
has  so  many  plausible  facts  to  support  it,  but  was 
obliged  to  modify  his  opinion,  as  I  have  since  done 
mine. 

He  found  that  crepitant  rales,  in  some  cases,  could  be 
proved  to  be  due  to  the  presence  of  thin  fluid  in  the 
pleural  cavity  (Walshe  on  Diseases  of  the  Chest,  pp.  107 
and  108,  3d  edition).  , 

In  Dr.  Chamberlain's  case  of  atheramatous  aorta 
(reported  in  the  New  York  Med.  Journal,  Oct.,  1874)  I 
had  the  privilege  of  making  a  careful  exploration  of  the 
patient's  chest  not  long  after  the  first  serious  symptoms 
were  manifested.  Over  the  lower  part  of  the  right 
lung  there  was  crepitus  or  fine  subcrepitus,  and  at  the 
autopsy  blood  was  found  in  the  right  pleura,  but  both 
the  pteura  and  lung  were  healthy. 

The  signs  of  bronchitis  of  greatest  diagnostic  im- 
portance are  not  rales,  but  raised  temperature,  quick- 
ened pulse,  with  harsh  and  sibilant  respiration,  which 
masks  true  respiratory  murmur  (it  does  not  supplant  it 
as  is  done  in  pneumonia),  with  appropriate  rational 
signs. 

When  resolution  takes  place,  then  true  mucous  rales 
are  heard  in  the  upper  bronchi,  distant  from  the  ear, 


INTERPLEURAL   PATHOLOGICAL   PROCESSES.  95 

and  at  longer  or  shorter  intervals,  as  it  is  collected  or 
expectorated.  Bronchitis  may  be  complicated  with 
pneumonia  or  pleuritis,  in  which  case  the  signs  will  be 
more  or  less  blended. 

Sympathy  between  the  bronchia  and  the  pleura  is 
very  intimate.  Severe  bronchitis  is  apt  to  induce 
plastic  exudation  between  the  pleurae,  and  plastic  exu- 
dation is  accompanied  more  or  less  with  bronchorrhoea. 
Foreign  bodies  in  the  bronchia  induce  plastic  exuda- 
tion between  the  pleuras  even  sooner  than  they  do 
pneumonitis. 

Capillary  bronchitis  may  or  may  not  be  accompanied 
by  rales ;  when  so,  they  have  their  origin  within  the 
pleural  cavity,  and  when  there  is  no  exudation  there  are 
no  rales.  This  is  a  disease  peculiar  to  children,  and  is 
really  pneumonitis  and  has  the  same  signs.  That  which 
is  generally  called  capillary  bronchitis,  on  account  of 
the  sign  of  small  moist  rale,  is  simply  an  interpleural 
plastic  exudation,  to  which  children  are  also  very 
liable. 

Fine  subcrepitus  may  or  may  not  accompany  pulmo- 
nary oedema,  but  only  when  there  is  exudation  of  some 
kind  within  the  pleurse. 

The  only  true  sign  of  pulmonary  oedema  is  dulness 
under  percussion.  It  is  not  distinguishable  from  pleu- 
ritic effusion,  except  when  there  are  fine  subcrepitant 
rales  as  well,  showing  that  the  pleural  surfaces  are  in 
coaptation  and  covered  with  lymph. 

The  diagnostic  signs  of  interpleural  pathological  pro- 
cesses may  be  briefly  stated  thus  :  Physical  signs — 
rales  or  rhonchi ;  large  gurgling  ;  soft  tearing,  harsh, 
dry,  rattling,  crackling,  small,  fine,  creaking.  Percus- 
sion note:  flat,  parchment-like,  wooden,  high  pitch, 
dull.  Rational  signs:  quickened  pulse,  hurried  respi- 
ration, dyspnoea,  asthma,  short  hacking  cough  when  the 


96  DISEASES   OF  THE   HEART  AND   LUNGS. 

adhesions  are  over  the  summit  and  upper  part  of  the 
lung;  spasmodic  and  strangling  when  in  the  lower 
pleurse.  Bronchorrhoea,  haemoptysis,  irritable  stom- 
ach, dyspepsia,  emaciation,  loss  of  strength,  frequent 
perspirations,  especially  when  sleeping;  and  lastly^ 
when  advanced  and  extensive,  all  the  signs  peculiar  to 
fibroid  phthisis. 


OK  HEMOPTYSIS.  9^ 


VI. 

On  HiEMOPtYsis. 

HAEMOPTYSIS  may  be  divided  into  two  kinds,  accord- 
ing- to  the  source  of  the  hemorrhage;  It  may  be  sim- 
ply an  exudation  through  the  bronchial  arteries  and 
mucous  membrane^-bronchorrhagia---or  it  may  come 
from  some  open  branch  or  branches  of  the  pulmonary 
artery — pneumorrhagia. 

These  sources,  though  both  in  the  respiratory  system, 
are  yet  widely  different  in  their  origin,  and  the  hemor- 
rhages differ  equally  in  their  character,  significance,  and 
danger.  One  comes  from  the  systemic  circulation,  the 
other  from  the  pulmonic.  One  signifies  obstruction  in 
the  capillary  circulation  within  the  lungs  ;  the  other 
that  there  is  destruction  of  lung  substance.  One  is 
not  necessarily  attended  with  danger,  the  other  threat- 
ens instant  death.  Different  and  yet  similar  as  are 
these  two  varieties  of  hemorrhage,  they  are  both  de- 
scribed to  the  popular  mind  rightly  enough  by  the 
common  term  "  bleeding  at  the  lungs,"  a  phrase  which 
conveys  to  the  people  only  an  idea  of  horror.  The 
few  cases  of  sudden  death  from  hemorrhage  of  the 
lungs  are  published  far  and  wide,  and  are  ever  remem- 
bered. When  one  spits  blood,  it  is  but  natural  that  all 
interested  should  fear  that  his  may  prove  one  of  the 
fatal  cases.  Public  fear,  as  well  as  other  forms  of  pub- 
lic opinion  in  regard  to  medical  subjects,  have  their 
origin  in  the  profession.  Through  the  profession  we 
hope  to  so  instruct  the  common  mind  as  to  prevent  un- 


98  DISEASES   OF  THE  HEART  AND   LUNGS. 

reasoning  fear,  and  in  this  way  it  seems  possible  we  may 
save  many  valuable  lives. 

Only  a  small  number  of  cases  of  blood-spitting  are 
fatal  of  themselves,  and  yet  many  of  them,  otherwise 
without  danger,  are  the  beginnings  of  fatal  illness, 
because  of  the  fright  Avhich  they  induce  and  of  the 
wrong  treatment  of  which  they  are  the  occasion.  The 
anatomical  explanation  of  these  facts  is  the  key  to  our 
comprehension  of  the  whole  subject.  The  bronchial 
mucous  membrane,  as  well  as  the  fibrous  sheaths  of 
the  bronchi,  are  supplied  with  blood  by  the  bronchial 
arteries,  which  blood  is  returned  by  the  bronchial  veins, 
and,  so  far,  the  analogy  of  this  circulation  to  that  of  the 
body  is  maintained.  But,  in  addition  to  this,  there  are 
in  the  lungs  arteries  arising  from  the  bronchial  perhaps 
receiving  supplies  also  from  the  intercostal  and  the 
mammary.  These  arteries  go  to  the  parenchyma  of 
the  lungs,  and  are  the  proper  nutrient  vessels  of  the 
true  respiratory  system.  (''Waters  on  the  Human 
Lung" — Reissiessen,  Cammann,  etc.) 

In  this  place  it  is  not  necessary  to  show  that  they 
alone  provide  nutrient  blood  for  the  whole  true  respi- 
ratory system  which  may  be  in  part  fed  from  the 
aerated  blood  of  the  capillaries  and  venous  radicles  of 
the  pulmonary  artery  and  vein.  The  exact  truth  on 
this  subject  will  probably  never  be  known.  The  sin- 
gular fact  remains  that  these  nutrient  arteries  have  no 
venae  comites.  Their  blood  makes  a  short  cut,  as  it 
were,  through  the  capillaries  of  the  true  respiratory 
system,  and  becomes  aerated  even  while  doing  its  work, 
and  IS  then  passed  immediately  into  the  radicles  of  the 
pulmonary  vein,  never  going  through  the  right  heart 
at  all,  and  may  be  said  never  to  have  left  the  systemic 
circulation.  This  anomalous  fact  in  the  vascular  anat- 
omy ot  the  respiratory  system  explains  how  bronchor- 


0h    tLEMOii  VSlb^        "  9^ 

'rhagia  may  be  caused  by  obstruction  of  the  pulmonary 
circulation.  Blood  hindered  or  arrested  in  the  pulmo- 
nary capillaries  obstructs  the  blood  in  the  nutrient 
arteries.  These  having  no  veins  accompanying"  are 
damned  up  and  the  blood  is  thrown  back  into  the  bron- 
chial arteries  ;  and  these  again  relieve  themselves  from 
the  accumulation  by  straining  it  through  their  own 
vascular  walls,  and  hence  this  is  called  bronchorrhagia. 
This  form  of  haemoptysis  is  a  safety-valve  arrangement, 
and  its  great  object  seems  to  be  to  prevent  injury  to 
the  true  respiratory  portion  of  the  lungs.  It  not  only 
prevents  immediate  injury,  it  does  more ;  it  stimulates 
the  organic  life  of  the  true  respiratory  system,  and  the 
absorbents  take  up  and  carry  off  the  obstruction, 
whether  it  be  plastic  exudation  upon  the  pulmonary 
pleura,  or  tubercle  in  the  air-sacs.  Bronchorrhagia 
may  arise  from  two  kinds  of  pulmonary  obstruction — 
from  that  which  is  temporary  and  extrinsic  to  the  pul- 
monary circulation  and  also  from  that  which  is  more 
permanent  and  which  has  its  seat  in  the  respiratory  sys- 
tem. The  first  cause,  or  extra  pulmonic,  may  be  from 
cardiac  disease,  hysterical  passion,  great  emotion,  or 
extraordinary  exertion.  The  second  is  from  obstruc- 
tion to  the  circulation  through  the  pulmonary  capilla- 
ries, as  by  plastic  exudation  upon  the  pulmonary  pleura, 
tubercles  in  the  air-sacs,  vesicular  emphysema,  cirrhosis 
of  the  lung,  cancer,  or  benign  tumor. 

Plastic  exudation  within  the  pleura  is  a  frequent  and 
too  generally  an  unrecognized  cause.  The  physical 
signs  of  plastic  exudation  have  either  been  called  sub- 
crepitant — sometimes  mucous  rales,  or  such  as  were 
supposed  to  indicate  capillary  bronchitis,  or  oedema  of 
the  lungs.  I  shall  not  here  attempt  any  discussion  of 
these  points,  as  that  has  been  partially  done  in  a  pre- 
vious paper  (Dr.  Brown-S^quard's  Archives  of  ScientifiQ 


100  DISEASES   OF  THE   HEART  AND   LUNGS. 

and  Practical  Medicine,  March,  1873),  but  shall  merely 
state  that  in  bronchial  hemorrhage,  it  is  practically 
safer  to  consider  these  rales  as  always  indicating  plastic 
exudation  within  the  pleura,  notwithstanding  any  pre- 
determined views  that  may  be  held  upon  this  subject. 
This  is  not  unimportant,  nor  is  it  intended  to  bar  dis- 
cussion, as  will  be  obvious,  it  is  hoped,  when  we  come 
to  speak  of  treatment.  The  rationale  of  this  cause  may 
be  readily  understood  if  we  consider  that  plastic  exuda- 
tion upon  the  pulmonary  pleura,  in  addition  to  the  pres- 
sure caused  by  its  presence,  soon  applies  that  cause 
effectually  by  its  contraction,  and  so  obstructs  the  cir- 
culation of  the  pulmonary  capillaries  immediately  sub- 
tending the  pulmonary  pleura. 

Tubercle  and  its  inflammatory  results  are  important 
causes  of  bronchorrhagia,  the  more  especially  as  the 
hemorrhage  may  draw  early  attention  to  the  disease, 
which  might  otherwise  have  remained  latent  until  soft- 
ening and  disintegration  of  tissue  had  commenced. 
There  is  no  controversy  as  to  the  importance  of  early 
knowledge  of  tuberculosis,  nor  as  to  its  correct  man- 
agement from  the  beginning.  Gray  tubercle — Bayle's 
tubercle — true  tubercle — may  be  so  deposited  as  to  ob- 
struct the  pulmonary  circulation  without  furnishing 
physical  signs,  except  such  as  are  obscure  to  the  gen- 
eral observer  and  liable  to  misinterpretation.  The  ex- 
pert auscultator  can  alone  read  them  with  certainty. 
In  both  tubercle  and  plastic  exudation  within  the  pleura 
the  capillary  circulation  of  the  true  respiratory  system 
is  impeded.  Hemorrhage  relieves  not  only  the  imme- 
diate circulation,  but  it  also  stimulates  the  absorbents 
to  remove  the  obstruction,  whether  it  be  tubercle  or 
plastic  lymph.  From  a  pretty  long  observation  of  clin- 
ical facts  I  feel  warranted  in  stating  my  conviction 
that  I  have  witnessed  this  conservative  process  in  not  a 


ON   HEMOPTYSIS.  lOI 

few  cases.  The  thoroug-hness  of  the  cure  may  depend 
upon  the  promptness  and  amount  of  the  hemorrhage. 
This  is  especially  so  in  first  attacks. 

When  either  of  the  important  causes  named  are  com- 
plicated with  inflammatory  products  in  the  pleura  or 
in  the  lung,  the  results  of  older  disease,  the  removal  of 
these  products  may  not  be  so  complete  ;  yet  even  then  a 
large  hemorrhage  may  do  very  much  to  clear  them  away. 

Vesicular  emphysema  gives  rise  to  another  variety  of 
obstruction  to  the  capillary  circulation  in  the  lungs. 
The  true  respiratory  system  consisting  of  bronchioli, 
infundibuli,  and  air-sacs  becoming  dilated,  bronchor- 
rhagia  sometimes  follows.  The  obstruction  to  the  capil- 
lary circulation  in  this  dilated  state  of  the  true  respira- 
tory system  results  from  the  elongation  and  narrowing- 
of  the  capillaries,  so  that  the  blood  flows  slowly  or  not 
at  all.  In  old  cases  of  emphysema  some  of  the  air-sacs 
become  destroyed,  which  still  farther  interferes  with 
the  circulation,  both  in  the  pulmonary  and  nutrient 
arteries,  but  with  less  liability  to  haemoptysis,  as  the 
system,  in  old  cases,  becomes  accustomed  to  the  crip- 
pled condition,  and  accommodates  itself  to  it. 

Cirrhosis  of  the  lung  is  another  variety  of  structural 
change,  frequently  accompanied  by  hsemoptysis.  It 
commences  generally  in  childhood  or  early  life,  and 
this  history  assists  in  making  a  correct  diagnosis.  The 
similarity  of  its  physical  signs  to  those  of  phthisis  in 
the  third  stage  makes  it  necessary  that  we  should  treat 
of  it  somewhat  particularly.  In  both,  there  are  dul- 
ness  under  percussion,  cracked-pot  sound,  and  cavern- 
ous respiration,  which,  if  in  the  upper  part  of  the  lung-, 
are  sometimes  accompanied  by  mucous  gurgling.  There 
will  be  also  in  both  cases  absence  of  true  respiratory 
murmur,  altered  and  exaggerated  broncho-respiratory 
murmur,  and  there  may  be  bronchial  or  tubal  breath- 


102  DISEASES   OF  THE   HEART  AND   LUNGS. 

ing.  There  may  be  also  these  rational  signs  in  com- 
mon ;  hasmoptysis,  cough,  expectoration,  and  dyspnoea. 
They  differ  in  history  and  in  many  of  the  rational  signs. 
Hectic,  loss  of  strength,  night  sweats,  emaciation,  and 
disease  or  disorder  in  other  organs,  liver,  stomach,  etc., 
all  belong  to  phthisis,  but  not  to  cirrhosis.  In  phthisis 
the  amount  of  circulating  blood  gradually  diminishes, 
not  so  in  cirrhosis;  there  is  no  cachexia  in  cirrhosis, 
but  it  is  generally  marked  in  phthisis.  Yet  the  diagno- 
sis of  cirrhosis,  during  an  attack  of  haemoptysis,  must 
be  difficult.  A  few  hints  may  assist  in  differentiation. 
The  cavities  in  cirrhosis  are  always  of  moderate  size 
and  regular  shape,  and  consequently  the  cavernous  res- 
piration is  smoother  in  character  and  softer  in  quality 
than  that  formed  in  the  irregular  excavations  of  phthisis. 
The  sound  runs  along  the  open  bronchus  each  way  in 
cirrhosis  more  readily,  and  is  conveyed  farther  from 
the  cavity  than  in  phthisis.  The  condition  of  the  diges- 
tive organs,  fulness  and  vigor  of  the  capillary  circura- 
tion,  but  above  all,  the  history  of  the  long  continuance 
of  the  case,  enables  us  to  make  a  correct  diagnosis.  The 
pathogenesis  of  cirrhosis  is  considered  to  be  as  follows : 
inflammation  of  the  bronchial  mucous  membrane  ex- 
tends to  the  enveloping  fibrous  sheath,  and  interstitial 
plastic  exudation  takes  place,  which,  contracting,  results 
in  stricture  of  the  bronchus,  and  dilatation  follows  be- 
hind the  stricture.  In  new  attacks  of  bronchitis,  plastic 
matter  is  thrown  outside  of  the  sheath,  enveloping  and 
destroying  some  of  the  air-sacs  and  bronchioles.  As 
the  child  grows  older,  the  physical  signs  give  evidence 
of  cavities  and  consolidated  lung.  This  condition  of 
the  bronchi  becomes  more  or  less  complicated  with  plas- 
tic exudation  within  the  pleura,  which,  suddenly  inter- 
fering with  the  capillary  circulation  of  the  periphera,I 
air-sacs,  may  be  followed  by  bronchorrhagia. 


ON  HEMOPTYSIS.  IO3 

Cancer  and  benign  tumors  within  the  chest  may  also 
cause  haemoptysis  by  mechanical  pressure,  obstructing 
the  pulmonary  circulation.  But  the  cases  are  rare,  and 
it  is  not  necessary  to  dwell  upon  them,  for,  if  there  be 
obscurity  at  first  in  the  physical  signs,  the  rapid  prog- 
ress of  malignant  disease  soon  renders  the  diagnosis 
clear. 

Pneuinorrhagia, — The  second  grand  division  of  this 
subject  is  important  on  account  of  its  great  fatality. 
Fortunately  its  class  is  small,  yet  the  terror  which  it 
excites  is  not  unlike  that  produced  by  the  cry  of  fire  in 
a  large  assembly,  jeopardizing  many  more  lives  by  the 
fright  and  insane  action  which  it  induces  than  by  any 
intrinsic  danger  in  the  thing  itself.  Pneumorrhagia 
implies  an  eroded  branch  of  the  pulmonary  artery.  For 
practical  purposes  we  shall  consider  it  merely  as  the 
effect  of  erosion  from  disease,  presupposing  a  cavity  to 
have  been  formed.  Yet,  even  in  the  third  stage  of 
phthisis  pneumorrhagias  are  rare  among  the  number 
of  hemorrhages.  Pneumorrhagia  is  possible  after  the 
rapid  formation  of  a  cavity,  and  becomes  probable  if 
the  cavity  be  near  the  root  or  centre  of  the  lung,  where 
the  vessels  are  large  and  abundant.  The  rapid  disin- 
tegration of  tissue  renders  the  branch  of  the  pulmonary 
artery  which  passes  across  or  through  the  decaying 
mass  liable  to  morbid  change,  which  may  take  the  form 
either  of  disruption,  resulting  in  sudden  death,  or,  by 
shrinking  up,  become  impervious,  and  so  remain  for 
years.  It  is  then  a  matter  of  great  moment  to  watch 
the  formation  of  cavities,  in  what  may  be  called  a  dan- 
gerous position,  and  to  so  guard  the  patient  during  the 
unavoidable  process  as  to  render  this  accident  of  mini- 
mum probability.  Severe  coughing  should  in  such  cir- 
cumstances be  allayed  by  opiates,  which  before  perhaps 
had  been  avoided.     Exertion  and  emotion  should  not 


104  DISEASES  OF  THE  HEART  AND  LUNGS. 

be  permitted  to  unduly  distend  the  pulmonary  vessels. 
Small  blisters  may  be  constantly  changed  from  place  to 
place  over  and  around  the  forming-  or  formed  excava- 
tion, in  order  to  glue  the  pulmonary  and  costal  pleura 
together,  preventing  motion  in  that  portion  of  the  dis- 
eased lung  long  enough  for  a  clot  to  be  firmly  formed 
in  the  artery.  Nature  sets  us  the  example,  for  no  cav- 
ity appears  near  the  surface  of  the  lung  but  that  its 
immediate  vicinity  is  bound  down  by  adhesions.  Reiss- 
eissen,  Marshall,  Hall,  and  others,  taught  that  the  anas- 
tomosis of  the  pulmonary  arteries  was  general  and  free. 
Dr.  Cammann  (iV.  V.  Med.  Journal,  1848),  in  his  experi- 
ments, by  a  series  of  injections  into  the  blood-vessels 
of  the  lung  of  the  sheep,  proved  clearly  that  this  was 
a  mistake  ;  that  instead  of  there  being  free  anastomosis, 
there  is  properly  none  at  all.  Each  lobulette  is  a  com- 
plete type  of  the  lung  and  has  no  anastomotic  connec- 
tion with  any  other  part,  so  that,  ordinarily,  cavities  in 
phthisis,  gangrene,  or  abscess,  are  rarely  accompanied 
by  pneumorrhagia,  and  only  so  by  the  accident  of  their 
opening  a  branch  of  the  pulmonary  artery.  If  the  cav- 
ity just  formed  is  centric,  with  no  pleuritic  adhesions, 
the  rational  signs  may  have  been  so  slight  as  not  to 
have  drawn  attention.  The  patient  may  be  in  attend- 
ance upon  ordinary  duties  when  the  first  mouthful  of 
blood  is  raised.  A  lady-teacher  in  one  of  the  public 
schools  is  standing  before  her  class,  giving  instruction, 
when  she  raises  a  mouthful  of  blood,  and  immediately 
retires  to  a  side  class-room ;  the  blood  pours  from  her 
mouth  and  nose  and  she  falls  to  the  floor,  and  is  dead 
before  a  messenger  can  be  despatched  for  help.  A 
gentleman  in  his  bed-chamber  touches  the  bell,  and 
comes  to  the  head  of  the  stairs  with  a  vessel  in  his 
hand,  and  calls  to  the  family  that  he  is  spitting  blood, 
and  desires  a  physician.     They  hasten  to  his  assistance 


ON   HEMOPTYSIS.  I05 

but  he  has  fallen  upon  the  floor  and  is  dead  when  they 
reach  him. 

Sudden  deaths  from  pulmonary  hemorrhage  are  rare, 
but  they  sometimes  occur.  Other  cases  of  pneumor- 
rhagia  are  not  so  immediately  fatal ;  there  may  be 
several  attacks  before  the  patient  succumbs.  The 
cavity  may  be  small,  and  the  open  branch  small,  or 
the  motion  in  the  diseased  lung  may  be  resisted  by 
pleural  adhesions.  In  the  latter  case  it  is  possible  the 
hemorrhage  may  be  arrested  permanently.  A  clot  form- 
ing in  and  filling  a  cavity  in  a  portion  of  lung  1  estrained 
from  motion  may  remain  there  long  enough  for  the 
eroded  artery  to  shrink  and  become  impervious.  But 
even  if  the  cavity  be  small,  and  the  arterial  branch 
small,  the  frequent  recurrence  of  hemorrhages  may 
finally  exhaust  the  patient.  This  form  of  hemorrhagia 
may  be  mistaken  for  bronchorrhagia  occurring  after 
extensive  plastic  exudation  within  the  pleura.  But 
with  the  absence  of  cavernous  respiration  or  signs  of 
consolidation  of  the  lung,  and  with  the  presence  of 
plastic  or  subcrepitant  rales,  the  diagnosis  need  not  be 
uncertain. 

Diagnosis, — It  needs  no  argument  nor  further  accu- 
mulation of  evidence  to  show  the  great  value  of  a  clear 
and  correct  diagnosis  of  hasmoptysis.  It  is  of  the  first 
importance  to  diagnosticate  between  bronchorrhagia 
and  pneumorrhagia.  In  a  large  proportion  of  cases  the 
medical  attendant  may  state  in  the  most  emphatic  man- 
ner that  there  is  no  danger,  and  refuse  useless  or  harm- 
ful medication.  His  presence  and  the  confidence  which 
he  inspires  relieves  apprehension  and  fright,  and  by 
wise  advice  he  may  prevent  serious  consequences.  The 
chances  are — perhaps  a  thousand  to  one — that  a  case  of 
hemoptysis  is  bronchorrhagia.  It  is  best  to  assume 
this   until  a  certain    diagnosis  proves  the  contrary — 


I06  DISEASES   OF  THB»  HEART   AND    LUNGS. 

which  turns  on  the  presence  of  cavities  and  consolida- 
tion of  pulmonary  tissue.  If  there  be  no  cavernous 
respiration  and  no  evidence  of  consolidation  and  in  ad- 
dition, if  respiratory  murmurs  can  be  heard  throughout 
the  lungs,  it  is  clear  that  there  can  be  no  cavities.  This 
determines  definitely  for  the  larger  number  of  cases, 
and  those  not  thus  determined  may  be  classed  as  doubt- 
ful in  virtue  of  the  same  negative  evidence.  By  farther 
examination  we  may  satisfy  ourselves,  almost  with  cer- 
tainty, that  a  large  majority  of  these  also  are  cases  of 
bronchorrhagia.  If  the  walls  of  the  cavities  are  hard 
and  unyielding  it  amounts  almost  to  a  demonstration 
that  the  hemorrhage  is  not  pneumorrhagia,  for  the 
hardened  walls  are  a  sign  that  the  cavities  are  old,  and 
the  branches  of  the  pulmonary  artery  that  traverse  them 
are  probably  impervious.  If  cirrhosis  of  the  lung  be 
diagnosticated,  it  is  certain  that  the  hemorrhage  cannot 
be  pneumorrhagia.  When  a  cavity  is  forming,  or  has 
just  formed,  without  previous  disease  in  that  portion  of 
the  lung,  if  the  position  be  central,  the  progress  of  the 
disease  rapid,  and  the  lung  free  in  its  motion,  not  held 
by  adhesions,  the  danger  from  pneumorrhagia  is  immi- 
nent and  should  be  guarded  against. 

Treatment. — Pneumorrhagia  may  be  so  speedily  fatal 
that  there  will  be  no  time  for  ordinary  remedial  meas- 
ures. It  has  been  suggested  that  it  might  be  possible 
to  arrest  hemorrhage  from  the  lungs  likely  to  be  fatal 
by  standing  the  patient  upright  until  syncope  should 
take  place,  and  then  placing  him  in  a  recumbent  posi- 
tion, so  that  a  clot  might  form  in  the  cavity.  I  am  not 
aware  that  this  plan,  which  certainly  has  plausibility  to 
recommend  it,  has  ever  been  intentionally  tried  in  prac- 
tice. But  we  know  that  some  of  the  patients  were 
standing  upright  when  the  bleeding  began,  and  fell  from 
exhaustion  or  syncope,  and  so  had  the  advantage  of 


ON  HEMOPTYSIS.  10/ 

this  hypothetical  method  without  avail.  The  appalling 
cases  of  pheumorrhagia  arise  from  central  cavities  of 
large  size  and  from  the  erosion  of  a  large  vessel. 
Should  a  clot  even  be  formed  and  the  patient  recover 
from  syncope,  the  unhindered  motion  of  the  free  lung 
would  soon  dislodge  the  clot,  and  the  hemorrhage 
would  again  commence.  Unfortunately  the  history  of 
these  cases  shows  that  they  are  too  speedily  fatal  for  a 
clot  to  form.  In  a  small  cavity,  or  in  a  smaller  open 
vessel,  there  is  more  likelihood  of  the  formation  of  a  clot, 
and  the  temporary  arrest  of  the  hemorrhage.  But  even 
here,  when  the  cavity  forms  in  the  centric  or  dangerous 
locality,  the  clot  is  soon  dislodged  and  the  bleeding  re- 
commences, and  this  alternation  continues  till  the  patient 
sinks  exhausted.  In  this  variety  of  pneumorrhagia, 
however,  there  is  time  for  something  to  be  done ;  the 
danger  is  from  recurrence  of  bleeding  by  displacement 
of  the  clot.  If  this  can  be  pievented  long  enough  the 
vessel  may  become  impervious  and  immediate  death  be 
avoided.  There  can  be  no  hope  to  fill  the  indication 
but  by  mechanical  interference ;  medicines  have  no 
power  over  open  vessels  in  the  centre  of  the  lung.  Our 
experience  suggests  that  nature  has  here  pointed  the 
direction  that  our  endeavor  must  take  to  afford  any 
hope  of  success.  Motionless  lung  alone  can  permit  the 
closing  of  the  vessel.  Nature  secures  this  condition  by 
adhesions — we  can  in  some  degree  imitate  her  by  trans- 
fixing the  lung  in  the  diseased  part,  thus  holding  it  still 
till  the  danger  is  past.  Needles  of  platina  or  gold,  passed 
from  different  points  through  the  lung,  may  successfully 
prevent  motion,  and  they  might  remain,  doing  no  seri- 
ous injury,  until  inflammatory  action  should  be  set  up, 
and  thus  effectually  prevent  a  recurrence  of  hemmor- 
rhage.  Or  the  needle  of  the  aspirator  could  be  passed 
into  the  cavity  and  an  injection  of  a  drop  or  two  of 


I08  DISEASES   OF  THE   HEART  AND   LUNGS. 


liquor  ferri  persulphatis  or  other  powerful  styptic  could 
be  thrown  in,  which  would  form  a  firm  clot  in  the  open 
vessel  as  well  as  in  the  cavity,  and  the  hemorrhage  be 
permanently  arrested.  This  presupposes  an  accurate 
diagnosis  of  the  position  of  the  cavity.  As  before  said, 
fatal  pneumorrhagia  is  not  likely  to  occur  near  the  sur- 
face of  the  lung,  where  the  contiguous  pleura  is  bound 
down  by  abundant  adhesions,  and  it  is  a  wise  precau- 
tion to  frequently  apply  small  blisters  over  and  around 
forming  or  recently  formed  cavities.  This  measure  not 
only  guards  against  pneumorrhgia,  but  it  prevents  a 
cavity  discharging  its  contents  into  the  pleura,  causing 
hydro-pneumo-thorax.  Effusion  of  serum  into  the  pleu- 
ral cavity  arrests  pneumorrhagia  by  mechanical  com- 
pression, in  the  same  way  as  we  sometimes  see  it  crush 
out  pneumonia.  This  condition  might  be  artificially 
produced  by  pumping  water  into  the  pleura.  Ligatur- 
ing the  limbs  with  a  tourniquet  or  strap  is  easily  per- 
formed, and  it  is  a  practical  and  frequently  used  method 
of  arresting  hemorrhages,  for  it  prevents  the  return  of 
venous  blood  to  the  right  side  of  the  heart,  and  tempo- 
rarily relieves  the  pressure  on  the  pulmonary  circula- 
tion. The  hemorrhagic  act  is  preceded  and  accompanied 
by  an  eager  hastening  pulse-beat,  which  the  medical 
observer  soon  recognizes,  and  advantage  may  be  taken 
of  this  monition  to  gain  time  for  the  application  of 
mechanical  means.  If  some  of  these  means  suggested 
seem  to  be  harsh,  farther  consideration  will  show  that 
they  are  not  so  in  realitv,  and  it  must  be  remembered 
that  the  occasion  is  desperate  and  none  other  are  of  any 
use  or  promise  any  hope.  Medicines  given  by  the 
mouth,  or  otherwise,  can  have  no  control  over  a  bleed- 
ing artery  in  the  centre  of  the  lung. 

In  bronchorrhagia  there  is  no  danger  of  sudden  death, 
and  consequently  there  is  time  to  select  the  best  meth- 


ON   HEMOPTYSIS.  109 

ods  oi  treatment.  When  the  cause  is  extrinsic  to  the 
lungs  the  remedy  should  be  to  the  cause  and  not  to  the 
symptoms.  In  hysteria  the  treatment  should  be  to  the 
disease,  and  the  same  in  cardiac  affections.  The  hem- 
orrhage per  se  gives  relief,  and  when  left  to  itself  it  may 
be  safely  said  is  never  other  than  beneficial.  After  an 
hysterical  hemorrhage  from  the  lungs,  v^hich  may  have 
produced  alarming  fright  in  the  bystanders,  the  patient 
may  fall  into  a  gentle  and  placid  sleep,  from  which  she 
awakes  relieved. 

Bronchorrhagia  arising  from  obstruction  to  the  pul- 
monary circulation  from  a  diseased  heart  must  be 
treated  by  paying  attention  to  the  heart  alone,  endeav- 
oring to  give  it  force  and  power  to  equalize  the  circu- 
lation. Stimulating  enemata,  brandy  by  the  mouth, 
mustard  foot-baths,  the  sedative  action  of  calomel,  digi- 
talis and  nux  vomica,  may  relieve  the  heart  from  its 
oppressed  condition,  and  the  hemorrhage  will  cease 
naturally.  Bronchorrhagia  resulting  from  obstructed 
pulmonary  circulation,  caused  by  plastic  exudation 
upon  the  pulmonary  pleura,  is  of  more  frequent  occur- 
rence than  any  other,  and  its  mismanagement  may  be 
followed  by  the  most  serious  consequences.  The  lung 
oppressed  by  the  presence  of  plastic  exudation  is  more 
and  more  crippled  by  contraction.  A  large  hemorrhage 
at  the  beginning  is  frequently  followed  by  the  immedi- 
ate removal  of  the  cause.  Attempts  to  arrest  this  hem- 
orrhage are  generally  futile,  but  the  evil  results  of  the 
methods  used  and  the  delay  in  applying  proper  reme- 
dial measures  may  end  in  what  is  popularly  known  as 
"  hasty  consumption."  The  old  custom,  lately  reinstated 
by  the  translation  of  a  popular  German  text-book,  is  to 
place  the  patient  in  bed  in  a  semi-recumbent  position, 
to  direct  that  he  be  kept  quiet,  to  speak  only  in  whis- 
pers, not  to  cough,  to  darken  the  room,  and  prevent  all 


no  DISEASES   OF  THE   HEART   AND   LUNGS. 

motion  that  may  be  avoided.  In  addition  to  this  medi- 
cines are  given  to  stop  the  hemorrhage,  as  acetate  of 
lead,  opium,  kino,  tannic  acid,  gallic  acid,  mattico,  ergot, 
spirits  of  turpentine,  and  table-salt.  In  spite  of  all  this 
treatment  and  mismanagement  the  bleeding  continues 
more  or  less  at  intervals,  causing  prostrating  fear  to  the 
patient  and  agony  to  the  loving  attendants.  This  may 
go  on  for  days  or  weeks,  until,  nature  giving  up  the 
contest,  the  bleeding  may  cease,  only  to  be  followed  by 
disintegration  of  tissue,  rapid  tuberculosis,  and  death. 
An  entirely  opposite  treatment  might  have  saved  life. 
But  instead,  the  effort  of  nature  is  thwarted  and  ren- 
dered of  no  effect.  The  threatening  conditions,  which 
she  would  have  changed  if  she  had  not  been  prevented, 
are  carefully  preserved,  and  in  addition  to  all  this  the 
exuded  blood  is  kept  in  the  bronchi  decaying  and  offen- 
sive, causing  local  inflammation  and  general  depression. 
Medicines  which  do  harm  to  the  patient,  and  do  not 
arrest  the  bleeding,  are  resorted  to,  while  all  that  should 
be  done  is  left  undone.  It  is  no  wonder,  viewed  in  this 
light,  that  "  hemorrhage  causes  phthisis ;"  would  it  not 
be  better  to  say,  rather,  that  the  physician  cultivates 
phthisis?  As  illustrating  the  possible  consequences  of 
repressing  all  effort  to  relieve  the  clot  in  cases  of  hem- 
orrhage, there  is  an  instructive  case  in  Graves,  who 
reports  the  incident  of  a  gentleman  who  had  several 
hemorrhages  in  one  day,  and  was  visited  by  Dr.  Stokes, 
who  found  him  collapsed  (he  had  also  been  bled  from 
the  arm)  and  well-nigh  asphyxiated  ;  the  right  side  of 
his  chest  was  expanding  and  contracting  energetically, 
the  left  almost  fixed  and  motionless.  Dr.  Stokes  changed 
his  position  and  gave  him  a  glass  of  wine,  when  he 
made  an  effort  and  violently  expectorated  a  fibrinous 
coagulum,  forming  a  complete  mould  of  the  left  bron- 
chus and  its  ramifications.    Loevenhard,  quoted   by 


ON  HEMOPTYSIS.  in 

Valleix,  cites  a  case  of  a  woman  to  whom  alum  had 
been  administered  in  haemoptysis  with  the  hope  of  ar- 
resting the  hemorrhage,  and  apparently  with  effect,  but 
upon  the  cessation  of  the  bleeding,  suffocation  became 
imminent;  and  from  this  danger  the  woman  was  only 
reheved  by  the  rejection  of  a  large  quantity  of  coagu- 
lated blood. 

What  then  should  the  physician  do  when  called  to  a 
case  of  this  nature  ?  His  first  determination  should  be 
to  do  no  harm.  He  should,  by  his  cheerful,  confident 
demeanor,  inspire  the  patient  and  friends  with  his  own 
courage.  Then  after  auscultation  and  the  diagnosis  of 
bronchorrhagia,  he  should  insist  upon  the  patient's 
speaking  aloud,  that  he  should  breathe  freely,  sit  up, 
walk  about,  cough  and  expectorate  all  the  blood  he 
can.  There  is  no  danger  of  increasing  the  hemorrhage 
by  coughing,  loud  speaking,  and  full  respiration  ;  these 
acts  merely  help  to  loosen  and  dislodge  the  blood 
already  exuded  into  the  bronchi,  and  which  is  there 
obstructing  respiration.  It  should  be  the  object  of  the 
treatment  to  expel  all  the  exuded  blood  before  any 
part  of  it  becomes  putrid.  Clearing  out  the  bronchi 
and  full  respiration  do  not  increase  the  exudition ;  on 
the  contrary,  these  healthful  acts  go  far  to  equalize  the 
circulation  and  help  to  arrest  farther  hemorrhage.  Salt 
and  spirits  of  turpentine  are  innocuous,  but  do  not  let 
the  patient  believe  that  they  are  given  for  the  purpose 
of  arresting  hemorrhage  ;  it  is  best  to  stand  firmly  upon 
the  ground  that  the  hemorrhage  is  beneficial  and  should 
not  be  arrested.  On  this  account  we  should  refuse  any 
medication,  for,  if  the  bleeding  does  not  soon  cease,  the 
patient  begins  to  lose  confidence  in  the  doctor's  ability 
to  arrest  it,  which  may  be  calamitous.  The  confidence 
inspired  by  the  presence  of  one  believed  to  have  power 
to  help  us,  gives  tranquillity  of  mind  and  that  steady, 


112  DISEASES   OF  THE   HEART  AND   LUNGS. 

nervous  action  which,  operating  directly  on  the  heart, 
equaHzes  the  circulation  ;  the  cold  extremities  become 
warm,  the  oppressed  breathing  becomes  free,  and  these 
facts  prove  that  the  pulmonary  congestion  or  stasis  is 
relieved.  Many  remedies  have  gained  reputation  for 
power  they  did  not  possess,  by  the  real  power  of  a  trusted 
physician's  presence,  acting  through  the  emotions  upon 
the  organic  life  of  the  body.  As  soon  as  a  diagnosis  can 
be  made  between  plastic  exudation  and  early  tubercu- 
losis, a  line  of  treatment  should  be  adopted  not ''  to  cure 
the  bleeding,"  but  to  remove  the  cause.  In  both  plastic 
exudation  and  early  tuberculosis  all  the  special  treat- 
ment should  be  the  same.  The  lungs  should  be  fre- 
quently and  systematically  expanded  ;  as  much  fresh  air 
should  be  inspired  as  the  system  will  accept.  The  diet 
should  be  nutritious,  not  overstimulating,  but  such  as  is 
known  to  be  most  beneficial  in  tubercular  phthisis.  If 
plastic  exudation  should  be  diagnosticated  by  finding 
persistent,  subcrepitant  or  mucous  rales,  soft-tearing 
and  near  the  ear,  without  dulness  of  the  percussion 
note,  its  early  removal  would  be  an  object  of  the  high- 
est importance.  Nothing  helps  us  in  this  object  more 
speedily,  perhaps,  than  the  bleeding  itself,  and  for  this 
reason  we  should  not  arrest  it,  even  were  it  within  our 
power  to  do  so.  The  beneficent  and  harmless  action  of 
calomel  when  used  for  its  sedative  effect,  in  cases  of 
commencing  or  threatened  inflammation,  is  not  so  well 
known  as  it  deserves  to  be.  In  "  Graves'  Clinical  Medi- 
cine" (pages  803-806  inclusive,  ed.  1843,  Dublin),  its 
qualities  and  capabilities  are  well  set  forth.  In  Dr. 
Lente's  paper  {N.  Y.  Jour,  of  Med:,  May,  1869),  its  suc- 
cessful and  safe  application  in  dysentery  and  some  other 
inflammations  is  ably  maintained.  In  recent  plastic 
exudation,  followed  by  hemorrhage,  its  beneficent  and 
prompt  effects  are  more  remarkable  than  they  are  in 


On  hemoptysis.  113 

any  other  inflammation.  It  wipes  out,  as  it  \vefe,  all 
evidence  of  disease,  the  hemorrhage  ceases,  the  subcrepi- 
tant  and  mucous  rales  disappear  in  an  incredibly  short 
time,  leaving  the  patient  well.  It  has  been  unfashion- 
able of  late  years  to  speak  of  calomel  and  bleeding 
as  proper  remedies  in  any  case.  No  doubt  they  have 
been  as  abused,  and  so  too  have  many  other  good  ins- 
truments which  have  not  been  discarded. 

Above  all  other  things  it  is  important  that  specifics 
or  styptics,  of  whatever  name  or  character,  especially 
those  that  may  depress  the  vital  power  or  derange  the 
digestive  organs,  should  be  withheld  in  bronchorrhagia. 
Our  one  object  should  be  to  remove  the  cause. 


114  DISEASES   OF  THE   HEART  AND   LUNGS. 


VII. 

Endemic  Pleuro-Pneumonia,  as  Seen  in  New 
York  During  the  Past  Ten  or  Twelve 
Years. 

Typical  pleuro-pneumonitis,  such  as  may  occur  from 
a  wound  of  the  lungs  in  a  person  in  previous  health, 
even  when  followed  by  grave  constitutional  distur- 
bance, is  essentially  different  from  the  disease  called 
pleuro-pneumonia,  which  is  but  the  exponent  of  systemic 
perturbations  and  changes  resulting  from  differing  and 
mixed  causes. 

Endemic  pleuro-pneumonia  in  New  York  during  the 
last  ten  or  twelve  years  has  had  distinct  and  peculiar 
factors,  some  of  which  were  known  or  partly  under- 
stood while  others  were  unrecognized  or  obscure. 

We  are  apt  to  fix  our  minds  upon  the  obvious  and 
immediate,  thus  perhaps  directing  our  attention  away 
from  the  hidden  causes  which  may  give  the  disease  its 
peculiar  characteristics. 

Cases  of  ordinary  pneumonia  may  have  varying 
factors.  That  with  malarial  tendencies  differs  from  that 
with  typhoidal,  and  where  these  are  combined  the 
resulting  disease  has  characteristics  essentially  its  own. 

In  the  epidemic  of  ship  fever  in  New  York  in  1845 
to  1854  the  complications  by  pneumonia  were  not  rare 
nor  were  they  exceptionally  fatal  in  their  tendencies 
unless  as  influenced  by  peculiarities  of  nationality, 
which  were  factors  of  an  unknown  power.  The  Ger- 
man poor  were  not  so  liable  to  the  fever  as  the  poor 


ENDEMIC   PLEURO-i*NEUMONIA*  tlj 

Irish,  but  in  Ihem  pleuro-pneumonia  was  a  much  more 
fatal  complication.  Causes  which  are  plain  to  every 
observer  never  fail  to  attract  due  attention  but  those 
which  escape  ordinary  scrutiny  demand  patient,  dili- 
gent, and  enlightened  investigation. 

For  many  years  a  form  of  fatal  pleuro-pneumonia  has 
prevailed  in  the  cities  of  the  Southern  States,  while  in 
the  North  there  was  another  form  of  this  disease  of 
mild  type  and  easy  management.  At  the  same  time 
there  was  a  gradual  procession  of  the  fatal  form  north- 
ward overrunning  Washington,  Baltimore,  and  Phila- 
delphia, until,  about  1868,  it  reached  New  York.  A 
comparison  of  statistics  will  show  to  what  extent  it  has 
influenced  the  bills  of  mortality  since  then. 

In  1839,  ^^  ^  population  of  301,697,  the  whole  num- 
ber of  deaths  was  7361  ;  from  pneumonia  and  bron-- 
chitis,  568.  I  have  included  bronchitis,  as  I  have  nO' 
doubt  that  the  cases  so  reported  were  mostly  if  not  alL 
pleuro-bronchial  or  pleuro-pneumonic.  In  185 1  there 
was  a  sudden  and  noticeable  increase  of  deaths  from 
these  diseases.  In  a  population  of  545,359  the  whole 
number  of  deaths  was  20,738,  and  from  pneumonia  and 
bronchitis  1569. 

In  1856,  in  a  population  of  694,607,  the  whole  number 
of  deaths  was  20,102  ;  from  pneumonia  and  bronchitis, 
1 1 59,  which  was  a  falling  off. 

In  1868  there  was  again  an  increase  in  the  death 
rate  from  pneumonia  and  bronchitis.  In  a  population 
of  913,298  the  whole  number  of  deaths  was  24,889,  and 
from  pneumonia  and  bronchitis,  2471. 

In  1875,  in  a  population  of  1,041,886,  the  whole  num- 
ber of  deaths  was  30,709,  and  from  pneumonia  and 
bronchitis,  3913. 

In  1876,  population  1,055,535,  whole  number  of 
deaths  29,152  ;  from  pneumonia  and  bronchitis,  3756. 


Il6  DISEASES  OJF  THE  HEART  ANt)  LUNGS. 

In  1877,  population  1,069,362,  whole  number  of 
deaths  26,203  ;  from  pneumonia  and  bronchitis,  3181. 

In  1878,  population  1,083,371,  whole  number  of 
deaths  27,008  ;  from  pneumonia  and  bronchitis,  3472. 
The  fatality  being  greatest  in  1875"^* 

There  is  and  has  been  since  the  endemic  appeared  a 
dread  of  it  in  the  public  mind  of  New  York  hardly  ex- 
ceeded by  that  of  any  of  the  great  epidemics  which 
have  prevailed  heretofore. 

The  profession  too,  at  its  commencement,  had  reason 
to  be  alarmed,  for  many  of  the  cases  ran  so  rapidly  to- 
wards a  fatal  termination  that  curative  measures  were 
useless  before  the  gravity  of  the  case  was  compre- 
hended. The  disciples  of  Hahnemann,  as  well  as  those 
who  depended  entirely  upon  the  "  vis  medicatrix 
naturae,"  were  astonished  at  the  powerlessness  of  their 
feeble  efforts. 

The  disease  had  assumed  a  new  phase,  new  factors 
had  been  added  to  its  causation,  which  required  dili- 
gent investigation  in  order  that  it  might  be  successfully 
combatted.  In  connection  with  this  subject,  and  per- 
haps as  explanatory,  we  may  go  back  to  the  history  of 
an  epidemic  of  pleuro-pneumonia  which  had  its  origin 
in  Canada  during  the  war  of  18 12-15. 

It  first  attracted  attention  in  the  British  Army  by  its 
contagious  element  and  great  mortality.  It  soon  in- 
vaded the  American  lines  and  decimated  the  raw 
troops  unused  to  camp  life.  Many  of  the  sick  (hospital 
accommodations  being  poor)  were  given  leave  of 
absence  and  carried  the  contagion  to  the  cities  and 
even  into  sparsely  settled  country  districts. 

It  followed  the  course  of  travel  southward,  reaching 
Charleston  in  18 18  and  the  cities  of  Gulf  in  1820.  Here 

*  Compiled  from  the  records  of  the  City  Inspector  by  John  T.  Nagle, 
M.D.,  Dep.  Registrar  of  Records. 


ENDEMIC   PLEURO-PNEUMONIA,  IJ^ 

it  lost  its  contagious  element,  ceasing  to  be  epidemic, 
and  becoming  endemic  remained  as  one  of  the  specially 
fatal  diseases. 

Dr.  Samuel  Henry  Dickson  has  described  it  graphi- 
cally as  *'  pneumonia  typhoides,"  which  in  its  active  state 
must  have  been  similar  to  the  *'  pleuro-pneumonia  conta- 
giosa" of  the  cattle  herds  of  to-day.  It  was  known 
among  the  people  as  "  the  epidemic"  and  those  who  re- 
covered from  it  were  subject  to  "  bronchial  affections" 
ever  afterwards. 

From  these  and  other  facts,  and  with  our  present 
knowledge,  we  may  assume  that  the  disease  like  the 
cattle  disease  was  largely  characterized  by  extensive 
exudation  of  plastic  material  into  the  pleural  cavities. 

It  may  not  be  possible  to  prove  that  endemic  pleuro- 
pneumonia as  we  know  it  in  New  York  is  the  legiti- 
mate successor  of  the  contagious  pneumonia-typhoides 
of  1812-15,  but  there  certainly  is  more  than  a  probable 
connection,  and  in  seeking  for  the  effective  hidden 
causes  of  the  mortality  of  this  disease  we  cannot  dis- 
miss the  careful  consideration  of  its  inherited  tenden- 
cies as  well  as  of  those  which  are  known  to  be  tem- 
porary and  the  immediate  consequences  of  unusual  but 
varying  conditions.  As  illustrative  of  the  necessity  of 
considering  all  relative  facts,  we  may  cite  the  example 
of  the  celebrated  Dr.  John  Huxham,  of  Kent,  England. 
He  observed  the  weather  and  kept  careful  records  of 
the  wind,  temperature  and  rain-fall  in  order  to  connect 
these  meteorological  conditions  Avith  the  prevalent  dis- 
eases, especially  with  those  which  were  epidemic. 

The  first  volume  recorded  observations  from  1727 
to  1737,  and  the  second  from  1738  to  1747  inclusive. 
Afterwards  he  published  essays  on  fevers,  small-pox, 
pleuro-pneumonia,  pleurisies  and  "ulcerous  sore 
throats."      These  grew  gut  of  deductions  consequent 


Il8  DISEASES   OF  THE  HEAIrT   AND   LUNGS. 

Upon  making  his  weather  observations  and  noting  the 
behavior  of  diseases  under  these  influences.  The  first 
first  chapter  of  his  dissertation  on  ''  pleurisies  and  peri- 
pneumonias"  is  of  the  power  of  the  winds  and  seasons 
in  producing  these  distempers. 

He  quotes  Hippocrates  "cold  northeasterly  winds 
brings  on  disorders  of  the  breast,  sides,  and  lungs," 
and  says:  "  This  hath  been  found  constant  and  true  by 
all  his  successors." 

''  Not  but  that  pleurisies  and  peri- pneumonias  espe- 
cially are  frequently  observed  in  other  constitutions  of 
the  air,  the  latter  very  often  supervening  on  other 
acute  fevers.  Yet  still  it  is  certain  these  two  diseases 
are  much  more  frequent  when  a  cold  dry  season  and 
northerly  and  easterly  winds  have  continued  for  any 
considerable  time."  He  also  says  ;  "  It  is  a  fact,"  casteri- 
bus  paribus,  "  blood  drawn  in  such  prevailing  constitu- 
tions of  the  atmosphere  is  constantly  found  more  dense 
and  viscid  than  in  long,  moist,  warm  seasons."  In  his 
history  of  the  epidemic  of  *' ulcerous  in  the  throat,'*  he 
records  the  state  of  the  weather  for  many  months  be- 
fore the  advent  of  the  disease.  "  The  weather  was 
pretty  cold  and  dry  in  March,  1752,  especially  at  the 
beginning  and  latter  end,  and  the  barometer  high.  At 
no  time  very  low. 

The  small-pox  grew  more  mild  and  much  less  fre- 
quent. The  other  diseases  also  less  common,  but  more 
inflammatory ;  no  malignant  sore  throats  ;  many  were 
severely  tormented  with  coughs  and  obstinate  asthmatic 
disorders.  The  blood  now  drawn  was  commonly  more 
dense  and  viscid  than  it  had  been  for  many  months.  At 
the  last  half  of  the  year  1752,  in  summing  up,  he  says  : 
*'  For  many  months  past  we  had  scarce  the  slightest 
fever,  but  it  was  attended  with  a  sore  throat,  aphthae 
and    some    kind    of    cuticular    eruption,     The    blood 


ENDEMIC   PLEURO-PNEUMONIA.  II9 

drawn  from  the  diseased  during  all  this  time  has  been 
very  rarely  viscid,  but  generally  florid,  seemingly,  espe- 
cially at  the  very  beginning  of  the  malady,  and  of  a 
very  loose  texture." 

We  see  that  Dr.  Huxham  was  a  devoted  student  of 
nature,  and  his  views  are  all  the  more  valuable,  inas- 
much as  he  was  not  a  slavish  adherent  of  any  school. 
His  accurate  description  of  "  The  Ulcerous  Sore  Throat 
Epidemic"  of  that  time  is  true  now  of  diphtheria,  and 
undoubtedly  was  the  same  disease. 

Brettonneau's  description  is  hardly  better,  and  it  is 
singular  he  should  say  "  Huxham's  ulcerous  sore  throat 
did  not  pertain  to  diphtheria,  but  rather  to  some  form 
of  scarlatina." 

It  must  be  that  Brettonneau  received  his  knowledge 
of  Huxham  at  second-hand.  He  could  not  have  said  so 
if  he  had  read  him  attentively. 

If  meteorological  records  had  been  kept  for  the  last 
hundred  years,  and  their  relation  to  epidemic  forms  of 
diseases  noted,  it  is  possible  that  we  would  have  had  a 
more  accurate  knowledge  of  devastating  epidemic  dis- 
eases and  also  of  the  best  methods  for  their  prevention 
and  cure. 

The  Weather  Bureau  at  Washington  might  combine 
with  its  meteoric  records  from  all  parts  of  the  continent 
one  of  the  sanitary  conditions — the  kind  and  form  of 
epidemics  and  their  peculiar  characteristics,  should  any 
exist. 

Public  health  associations  might  assiduously  collect 
such  facts  which  in  time  would  determine  the  existence 
of  sanitary  laws  of  which  we  are  at  present  ignorant. 

Lord  Bacon  says,  in  substance,  that  it  is  the  opinion 
of  some  that  the  conditions  of  weather  repeat  them- 
selves in  a  cycle  of  about  twenty-five  years,  and  that 
there  is  reason  for  such  belief.     The  popular  opinion 


126  DISEASES  OF  THE  HEART  AND  LUNGS. 

that  periodical  influences  of  the  heavenly  bodies  control 
health  has  some  foundations  in  fact.  We  know  that 
extraordinary  vicissitudes  of  weather,  violent  variations 
of  temperature,  winds,  moisture,  electricity  and  malaria 
—and  other  imponderable  agents  influence  health. 

There  are  disturbing  elements  which  determine  the 
particular  characteristics  of  epidemic  diseases.  Theo- 
ries are  abundant,  but  no  theories  are  of  great  utility 
which  are  not  confirmed  at  all  points  by  facts.  The 
germ  theory  supposes  that  the  unknown  factors  are 
floating  in  the  air,  and  produce  disease  by  entering  the 
circulation  of  the  blood.  At  all  events  this  is  plausible, 
and  may  aid  in  directing  attention  to  the  controlling 
hidden  cause.  Dr.  Huxham's  method  of  studying  the 
conditions  of  the  blood,  as  to  viscidity  and  coagulability, 
is  worthy  of  attention,  and  suggests  a  still  more  accu- 
rate way  by  means  of  the  microscope  and  by  chemical 
analysis  of  prognosticating  coming  epidemics.  Such 
knowledge  would  give  us  the  power  of  meeting  them 
at  the  commencement  and  of  rendering  them  innocuous. 
Yet  all  does  not  depend  upon  vicissitudes  of  weather. 

Before  the  appearance  of  Europeans  upon  this  conti- 
nent, it  is  said,  the  red  men  were  not  subject  to  devast- 
ating epidemics,  and  yet  the  meteoric  conditions,  we 
miay  infer,  were  not  greatly  different  from  what  they 
have  been  since,  except  as  modified  by  cutting  down 
the  forests  and  the  tillage  of  the  ground. 

The  vices  of  civilization  and  the  aggregation  of  people 
in  cities,  towns  and  camps,  are  the  elements  from  which 
epidemics  are  bred.  Human  filth  and  human  excesses 
shorten  the  average  life  of  the  race. 

In  order  to  show  the  change  of  type  in  pneumonia,  I 
will  premise  that  when  I  began  my  professional  life  I 
believed  as  I  had  been  taught,  that  active  interference 
was  u^possary  in  every  stage  of  the  disease,  to  prevent 


ENDEMIC   PLEURO-PNEUMONIA,  121 

destructive  inflammation.  But  I  soon  found,  and  by 
accident,  that  cases  would  get  well  without  active 
treatment.  That  the  expectant  plan  or  wise  manage- 
ment was  best.  Simple  medication  with  stimulants  and 
supporting  alimentation.  The  mortality  was  so  small 
that  it  seemed  unnecessary  for  an  uncomplicated  case 
to  reach  a  fatal  result.  It  was  the  belief  of  eminent 
practitioners  at  that  time,  whose  friendship  I  enjoyed, 
that  the  Asiatic  cholera  of  '32  and  '49,  and  the  ship  fever 
of  '47,  had  modified  the  type  of  inflammatory  diseases, 
and  made  a  change  in  the  treatment  necessary,  which 
was  then  becoming  fashionable.  Homoeopathy  had  an 
immense  advantage  in  this  change  of  type.  It  shook 
the  faith  also  of  some  high  in  the  profession.  Sir  John 
Forbes,  of  London,  and  Dr.  Bigelow,  of  Boston,  began 
to  teach  the  doctrine  of  self-limitation  of  diseases  and 
the  inutility  of  active  medication,  and  gained  many  ad- 
herents. When  the  fatal  forms  of  pneumonia  began  to 
occur  in  New  York,  about  ten  years  ago,  I,  with  other 
other  physicians,  was  surprised  at  the  failure  of  the 
managing  method,  and  the  frequency  of  fatal  termina- 
tions, and  I  became  impressed  with  the  truth  of  the 
proposition  that  with  the  change  of  type  there  had 
been  also  changes  in  the  pathological  process.  The 
cases  were  more  ''  typhoid,"  or  of  depressed  vitality, 
and  the  interpleural  complications  more  frequent  and 
of  graver  import.  Indeed  the  increase  of  mortality  was 
measured  by  these  complications.  Some  method  of 
treatment  more  efficient  was  necessary. 

The  late  Dr.  George  P.  Cammann,  whose  eminently 
practical  mind  led  him  to  investigate  the  peculiarities 
of  each  case  by  itself,  had  taught  us  that  in  cases  of 
great  and  sudden  congestion  of  the  lungs — the  very 
conditions  which  we  now  recognize  as  indications  of  in? 
terpleural  complication  ^nd  rapid  plastig  exudation— ^ 


122  DISEASES   OF   THE   HEART  AND   LUNGS. 

very  large  doses  of  calomel,  used  promptly,  would  con- 
trol the  disease  and  prevent  a  fatal  termination.  After 
his  death  I  caused  to  be  printed  a  paper  of  his,  which 
he  denominated  "  Sanguineous  Congestion  of  the 
Lungs,"  in  which  he  related  cases  treated  by  this  he- 
roic remedy.  The  dose  used  would  vary  from  ten  to 
sixty  grains,  according  to  the  urgency  of  the  case.  Dr. 
Cammann's  cases  were  accidental  and  occasional,  but 
no  doubt  were  the  same  as  the  endemic  pleuro-pneu- 
monia  of  to-day.  The  inefficiency  of  the  expectant 
method  rendered  a  resort  to  the  heroic  a  necessity,  and 
with  very  encouraging  results.  Cases,  such  as  had 
proved  fatal  by  the  mild  treatment,  were  saved  by  the 
prompt  exhibition  of  sedative  doses  of  calomel,  which 
are  less  depressing  to  the  system  than  smaller  doses  re- 
peated. I  am  aware  that  Mealhi  has  stated  that  more 
than  ten  grains  of  calomel  is  a  waste  of  good  medicine. 
This  statement  has  been  repeated  by  Headland,  and  is 
constantly  quoted  by  those  who  oppose  the  use  of  cal- 
omel having  no  practical  knowledge  of  its  wonderful 
efficacy  more  than  the  authors  quoted,  who  evidently 
knew  nothing  at  all.  But  the  difference  of  life  or  death 
many  times  depends  upon  the  prompt  exhibition  of  doses 
many  times  larger  than  ten  grains.  With  the  immense 
prejudice  operating  against  the  use  of  calomel,  it  re- 
quires the  courage  of  experience  to  give  the  very  large 
doses — twenty,  thirty,  forty,  or  even  sixty  grains  are  re- 
quired. The  medicine  is  not  thrown  away,  and  it  is 
safer  to  give  a  few  grains  more  than  might  barely  do 
than  to  repeat  the  dose. 

In  Graves's  Clinical  Medicine,  Dublin,  1848,  p.  803,  he 
says:  "If  a  person  is  seized,  for  example,  with  very 
acute  pericarditis,  how  unavailing  will  be  our  best  di- 
rected efforts  unless  they  be  seconded  by  a  speedy  mer- 
curiali^ation  of  the  system.     In  proof  of  this  assertion 


ENDEMIC   PLEURO-PNEUMONIA.  1 23 

I  might  adduce  a  considerable  number  of  cases  of  peri- 
carditis, treated  both  in  hospital  and  private  practice, 
and  might  triumphantly  compare  the  results  with  those 
obtained  in  the  Continental  hospitals,  as  recorded  by 
some  of  the  most  eminent  German  and  French  phy- 
sicians." 

Dr.  Graves  discusses  the  arguments  of  those  opposed 
to  the  free  use  of  mercury,  who  acknowledge  it  may  be 
necessary  to  use  it  in  hot  climates,  as  recommended  by 
Dr.  Johnson  in  his  classical  work,  but  who  deny  its 
utility  to  Europeans,  but  he  answers  that,  "this  obser- 
vation no  doubt  deserves  attention ;  but  its  weight 
falls  to  the  ground  if  experience  contrary  to  the  gener- 
ally received  opinion  shows  that,  with  proper  precau- 
tions, calomel  may  be  given  in  as  large  doses  here  as  in 
the  East  Indies."  And  again  he  says  *' another  most 
important  question  is,  whether  mercury  so  used  for  the 
cure  of  internal  inflammations  injures  the  constitution 
permanently.  With  the  greatest  confidence  I  can  an- 
swer it  does  not."  I  never  saw  a  single  bad  effect  fol- 
low the  use  of  mercury,  in  cases  where  the  first  conse- 
quences of  its  exhibition  was  the  rapid  and  complete 
removal  of  a  dangerous  inflammation."  To  all  of  these 
strong  expressions  of  one  of  the  greatest  clinical  teach- 
ers the  world  has  ever  known  I  can  give  my  entire  as- 
sent as  the  uniform  result  of  my  own  experience.  Dr. 
Graves  would  not  use  mercury  in  either  large  or  small 
doses,  except  from  necessity  when  death  and  perma- 
nent injury  might  be  avoided  and  where  no  other  means 
would  be  successful.  It  is  the  great  remedy  which 
may  be  held  in  reserve  when  all  others  fail.  The 
method  of  giving  it  is  dry  upon  the  tongue.  Dr. 
Graves  advises  to  wash  it  down  with  thin  gruel,  but  I 
believe  it  is  best  to  put  it  on  the  tongue  and  there  leave 
it,     Its  rapid  effect  shows  th^t  it  is  influential  or  before 


124  DISEASES   OF  THE   HEART  AND   LUNGS. 

entering  into  the  circulation,  for  many  times  it  would 
have  a  sensible  effect  in  controlling  the  heart's  action 
and  in  reducing  the  temperature  directly,  while  its  full 
beneficial  effects  may  not  be  had  in  twenty-four  hours. 
Many  times  the  patient  goes  quietly  to  sleep  in  an  hour 
who  had  previously  been  restless  and  sleepless,  resist- 
ing anodynes.  One  other  result  of  the  large  doses  of 
calomel  is  also  noted  by  Dr.  Graves,  which  is,  that 
when  internal  inflammation  is  rapidly  overcome,  tem- 
perature and  pulse  falling  with  subsidence  of  all  the 
alarming  conditions,  we  may  confidently  expect  the 
reparative  process  to  continue  until  all  is  cleared  up 
and  not  a  vestige  of  the  disease  remains.  But  that 
this  much  desired  object  may  be  obtained  the  full  seda- 
tive dose  must  be  given ;  just  enough  to  relieve  the  ur- 
gent symptoms  may  fail  to  clear  up  all  the  results  of 
inflammation. 

The  safety  of  the  large  dose  in  any  case  where  it  is 
indicated  at  all  is  absolute,  consequently  the  physician 
arriving  at  the  conclusion  that  the  sedative  dose  must 
be  given  should  not  fail  in  courage  to  complete  the 
work,  so  necessary  to  be  done,  by  any  half-way  meas- 
ures. 

The  following  case  is  given  in  detail  as  typical  of  en- 
demic pleuro-pneumonia  occurring  in  New  York  and 
vicinity  since  1869  and  uncomplicated  except  by  malaria 
and  sewer  gas  poison  : 

J.  R.  L.,  physician,  58  years  old,  in  good  health  ;  No^ 
vember  i6th,  1878,  at  u  o'clock,  had  a  prolonged  chill; 
about  I  P.M.  he  was  examined  by  Dr.  Hudson,  who 
found  crepitant  rales  in  the  posterior  lower  half  of  the 
left  lung,  with  dull  pain ;  temperature,  io5f  °;  pulse, 
160;  respirations  about  forty.  Thirty  grains  of  calo- 
mel were  placed  upon  his  tongue  at  once.  Tempera- 
ture immediately   commenced  to  f^ll — 104,    103,    102, 


ENbEMlC   PLEURd-PNEUMONIA.  12$ 

until  at  7  o'clock  it  was  99°.  However,  before  10  P.M. 
he  had  another  slight  chill,  after  which  his  temperature 
went  up  again  to  104^^°. 

November  17th,  before  noon,  had  another  chill,  and 
temperature  went  up  to  105°,  with  advance  of  physical 
signs.  Again  thirty  grains  of  calomel  were  placed 
upon  his  tongue,  and  again  the  temperature  began  to 
fall.  At  3  P.M.  it  was  104°;  at  5.15,  103°;  at  8.25,  102°. 
Monday  morning,  November  i8th,  if  was  101^°.  Dur- 
ing the  day  the  temperature  again  went  up  to  104°,  with 
slight  advance  of  the  rales  on  the  right  side.  After 
that  the  temperature  remained  not  higher  than  101°, 
until  the  seventh  day,  when  perfect  defervescence  took 
place. 

There  were  no  uncomfortable  conditions  caused  by 
the  calomel,  on  the  contrary  the  relief  was  almost  im- 
'mediate ;  within  half  an  hour  the  patient  was  sensible 
of  it. 

It  is  certain  that  the  large  doses  were  harmless. 
Possibly  it  would  have  been  better  had  the  full  drachm 
been  given  at  once.  At  all  events,  not  only  was  the 
disease  reduced  to  a  mild  character,  but  no  adhesions 
remained — no  disability.  The  entire  disappearance  of 
all  signs  of  fever  on  the  seventh  day  may  be  adduced 
as  evidence  of  its  natural  subsidence. 

But  would  it  have  been  so  had  the  calomel  not  have 
been  used  ?  I  think  not,  and  for  these  reasons.  In  the 
first  place,  the  attending  and  consulting  physicians, 
Drs.  Hudson,  Otis,  and  W.  N.  Jones  believed  that  he 
could  not  have  lived  until  the  seventh  day  had  the 
calomel  not  have  been  given,  and  secondly,  experience 
shows  that  where  there  is  a  large  amount  of  plastic  ex- 
udation, defervescence  does  not  take  place  on  the  sev- 
enth day,  but  the  fever  continues  indefinitely. 

The  rule  of  defervescence  applies  only  to  cases  in 


t26  DISEASES   OF  THE   HEART  AND   LUNGS. 

which  there  is  but  little  plastic  exudation  within  the 
pleura.  In  the  twenty-three  cases  of  pneumonia  re- 
ported by  the  Secretary  of  the  Committee  on  Therapeu- 
tics of  the  Therapeutical  Society  of  New  York,  treated 
with  large  doses  of  calomel,  there  were  twenty  recov- 
eries and  three  deaths.  But  this  heroic  treatment  must 
not  be  resorted  to  in  every  case.  Notwithstanding  the 
fact  that  endemic  pleuro-pneumonia  is  fatal  in  its  ten- 
dencies, other  cases  occur  at  the  same  time  which  are 
of  the  mild  type  and  in  which  the  tendency  is  to  get 
well,  and  in  such  mild  treatment  should  only  be  used. 

How  are  we  to  distinguish  the  mild  from  the  more 
serious  forms  of  the  disease  ?  First  by  the  rational 
signs  or  symptoms ;  second,  by  the  physical  signs.  In 
the  mild  form  the  respiration  is  not  greatly  oppressed, 
and  although  the  febrile  conditions,  pulse,  temperature, 
etc.,  may  denote  much  activity,  yet  from  the  fifth  to 
the  ninth  day  there  is  sudden  and  generally  complete 
defervescence  with  or  without  treatment,  and  the  con- 
valescence is  uninterrupted.  While  in  the  most  serious 
form,  there  is  dyspnoea  from  the  beginning,  lividity  of 
the  countenance,  restlessness,  and  seeking  the  upright 
position.  The  pulse  is  frequent  and  feeble,  the  skin 
cool  and  moist.  Temperature  may  run  very  high  or 
may  be  moderate.  There  is  no  natural  period  of  defer- 
vescence in  those  cases  which  survive  a  week  or  more. 
Many  times  the  patient  dies  before  the  fifth  day. 

The  differences  in  the  physical  signs  are  equally 
marked.  In  the  mild  form  the  pneumonic  conditions, 
sputa,  etc.,  are  sometimes  well  pronounced  for  days 
before  the  physical  signs  of  crepitant  rale  and  bronchial 
breathing  appear.  The  crepitant  rale  is  distinct  and  is 
not  mingled  with  subcrepitant  or  larger  rale,  until  the 
rd/e  redux  commences.  In  the  severe  variety  the  rales 
are  generally  mixed  and  begin  with  the  disease,  and  the 


ENDEMIC   PLEURO-PNEUMONlA.  12'; 

movement  of  the  lungs  is  notably  restrained.  Some- 
times there  is  but  moderate  dulness,  but  always  marked 
flatness  under  percussion.  The  rales  too  are  abundant 
and  varied  in  character.  All  these  differences  of  phy- 
sical signs  depend  upon  the  inter-pleural  complications. 
In  the  fatal  variety  there  is  a  large  amount  of  plastic 
exudation,  generally  in  both  pleura  and  frequently 
covering  a  greater  part  of  both  lungs.  In  one  the 
pneumonitis  is  the  principal  lesion,  in  the  other,  the 
inter-pleural  plastic  exudation.  Heretofore  I  have  en- 
deavored to  show  that  there  has  been  a  misconception 
of  the  significance  of  rales  as  a  physical  sign.  That 
they  are  not  interpulmonary  nor  inter-bronchial  as  a 
rule,  but  inter-pleural,  the  exceptions  being  in  larger 
mucous  rales,  which  are  generally  intermittent,  or 
gurgling,  when  formed  within  cavities  or  in  dilated 
bronchae. 

These  are  easily  and  certainly  diagnosticated  by 
their  distance  from  the  ear,  their  reverberation  in  the 
bronchas  and  not  being  conveyed  directly  into  the 
chest-wall.  There  are  great  differences  in  the  progress 
of  cases  of  the  mild  and  of  the  fatal  in  their  tendencies. 
The  mild  run  an  even  course,  and  their  day  of  conva- 
lescence can  be  prognosticated,  and  they  need  but  little 
medicine. 

The  others  have  no  regular  course  except  their  ten- 
dency is  to  a  fatal  termination.  The  hyperplasia  of  the 
blood  is  their  distinguishing  characteristic.  Exudation 
of  plastic  matter  into  the  natural  cavities  through 
serous  membrane  may  take  place  or  perhaps  bring  the 
patient's  life  to  a  hurried  end  by  the  formation  of  a 
heart  clot.  The  feebleness  of  the  heart's  action,  and 
quickening  pulse,  the  dusky  ashen  hue,  cold  clammy 
skin  and  spasmodic  respiration,  show  that  death  is  com- 
mencing at  the  heart. 


1^8  DISEASES  Oi'  THE  HEART  AND  LUNG^. 

I  have  frequently  demonstrated  to  my  own  satisfac- 
tion the  immediate  connection  between  these  signs  and 
symptoms  of  disease  and  the  plastic  pathology  of  the 
blood  and  its  exudation  into  serous  cavities  and  forma- 
tion into  clots  in  the  heart  and  great  blood  vessels. 
But  others  have  not  been  so  completely  convinced  as  to 
the  direct  interpretation  of  the  physical  signs  as  applied 
to  inter-pleural  processes,  on  account,  perhaps,  of  the 
time  elapsing  after  the  diagnosis  had  been  made  until 
its  verification  after  death. 

But  during  the  month  of  August  last  an  opportunity 
was  afforded  me  of  obtaining  proof  which  the  most 
sceptical  must  acknowledge  to  be  convincing. 

A  commission  appointed  by  the  U.  S.  Government, 
of  which  Gen.  Patrick  is  president,  Prof.  Lawe,  of 
Cornell  University,  is  a  member,  and  J.  D.  Hopkins, 
veterinary  surgeon,  is  inspector,  has  for  its  object 
stamping  out  contagious  pleuro-pneumonia  among  cat- 
tle. By  the  kindness  of  Dr.  Hopkins  and  the  commis- 
sion I  was  invited  to  be  present  at  the  destruction  of 
cows,  condemned  by  the  commission,  in  order  to  ex- 
amine them  before  death  by  auscultation  and  percus- 
sion, and  to  make  a  diagnosis  to  be  immediately  tested 
by  post-mortem  examination. 

On  the  19th  of  August  there  were  four  cows  con- 
demned and  to  be  destroyed  on  the  dock,  foot  of  38th 
Street  and  Hudson  River,  New  York.  In  each  of  the 
four  cows  suffering  with  acute  disease  of  a  few  days 
standing,  there  was  dulness  over  one  lung  with  raised 
pitch  in  percussion.  In  auscultation  there  were  rales 
over  the  affected  side  agreeing  with  the  locality  of 
pathological  conditions  of  the  pleura.  Where  there 
were  rales  there  were  always  adhesions.  Where  the 
rales  were  dry  and  harsh  in  character  the  adhesions- 
underneath  were  organized,  and  more  or  less  firm,     1£ 


Endemic  pleuro-pneumonia.  129 

the  rales  were  moist,  the  adhesions  were  moist  and  cel- 
lular. Where  the  rales  were  coarse  the  adhesions 
allowed  considerable  movement  of  the  lung  within  the 
chest  wall;  when  the  rales  were  firm  there  was  but 
little  motion,  the  lung  being  confined  by  close,  firm  ad- 
hesions to  the  chest  wall.  In  every  case  the  lung  was 
completely  solidified,  every  air  sac  distended  with 
exudative  matter,  so  that  the  whole  lung  occupied  its 
cavity  in  the  chest  to  distension,  and,  when  removed, 
was  a  solid  cone-shaped  mass,  standing  firm  of  itself 
and  keeping  its  form.  False  membrane  covered  the 
pleura,  and  extended  into  and  occupied  the  interlobular 
spaces,  and  the  cellular  tissue  around  the  bronchae, 
diminishing  their  calibre.  Wherever  there  was  cellular 
or  connective  tissue  there  was  plastic  exudation,  and,  if 
not  very  recent,  was  already  organized,  so  that  not  only 
the  whole  lung  was  thus  encysted,  but  each  lobulette, 
a  pathological  condition  peculiar  to  the  bovine  animal 
where  there  is  so  large  an  amount  of  connective  tissue 
in  the  lung. 

These  pathological  conditions  of  course  preclude  the 
entrance  of  air  into  the  lung  or  its  farther  distension  in 
attempted  respiration,  and  are  irresistible  evidence  that 
the  rales  heard  were  not  intrapulmonary  or  intrabron- 
chial,  and  therefore  must  be  intrapleural,  their  only 
source. 

On  the  27th  of  August  a  chronic  case  of  four  months* 
standing  was  slaughtered  for  beef  at  the  corner  of  First 
Avenue  and  Forty-fifth  Street.  The  cow  had  been  giv- 
ing thirteen  or  fourteen  quarts  of  milk  per  day.  I  was 
a  few  minutes  too  late  to  examine  her,  as  she  had  been 
killed  when  I  arrived,  and  the  post-mortem  examina- 
tion had  been  commenced.  The  affected  lung  was 
completely  disorganized  by  cheesy  tubercular  (so 
called)  degeneration,  and  broken  down  into  a  pulpy 
mass   of    a    yellowish,    whitish   color.     It    is    termed 


130  DISEASES   OF  THE   HEART  AND   LUNGS. 

"  encysted,"  as  the  abscesses  are  confined  by  the  false 
membrane  over  the  pleura  and  in  the  intralobular  and 
peribronchial  spaces. 

Dr.  Hopkins,  who  is  an  expert  auscultator,  told  me 
that  the  physical  signs  were  dulness  over  the  diseased, 
lung,  with  only  a  few  rales  and  rubbing  sounds  over 
the  diaphragm  and  over  the  shoulder,  over  sites  of  in- 
terpleural adhesions. 

On  the  28th  of  August,  at  foot  of  Thirty-eighth  Street 
and  Hudson  River,  on  the  dock,  two  cases  were  ex- 
amined. One  of  these  cases  was  acute,  and  as  usual 
one  lung  only  affected.  There  was  dulness  under  per- 
cussion, and  rales  over  the  affected  side,  agreeing  in 
locality  and  characteristics  with  the  interpleural  patho- 
logy. The  lung  Avas  impermeable  to  air.  The  second 
case  was  of  chronic  disease  of  the  lung,  but  was  not 
known  to  have  been  of  contagious  pleuro-pneumonia, 
and  was  of  about  six  months'  standing.  There  was 
marked  dulness  over  the  diseased  lung,  and  there  were 
rales  over  the  shoulder  and  over  the  diaphragm,  but 
none  between  these  points.  Post-mortem  examination 
showed  adhesions  where  the  rales  were  heard,  but  none 
over  the  middle  of  the  lung.  The  whole  lung  was 
carnified  and  covered  with  false  membrane.  On  the 
30th  of  August  one  cow  was  examined  and  killed  at  the 
foot  of  Thirty-eighth  Street  and  Hudson  River.  It 
was  an  acute  case  ;  the  cow  had  been  ill  but  a  few  days. 
There  was  complete  dulness  over  the  right  lung,  with 
bronchial  breathing  over  the  middle  portion,  without 
rales.  There  were  rales  over  the  shoulder  and  over 
the  diaphragm.  Post-mortem  examination  showed  con- 
solidated lung,  except  a  portion  of  the  under  and  lower 
part,  which  was  oedematous — false  membrane  covered 
the  lung  and  extended  into  the  intra-lobular  and  peri- 
bronchial spaces.  There  were  adhesions  at  the  dia- 
phragm and  under  the  shoulder,  but  none  intermediate, 


E:^^DEMIC   PLEURO-PNEUMONIA.  13! 

but  there  was  an  accumulation  of  fluid  separating  the 
pleurae  in  the  middle  of  the  lung-.  Over  the  oedema- 
tous  portion  there  were  no  rales  nor  over  the  middle 
portion  where  the  fluid  separated  the  pleura.  On  the 
left  side  auscultation  showed  the  respiratory  murmur 
muffled,  a  little  roughened,  but  by  close  attention 
moist,  almost  -unaudible,  soft,  rales  could  be  distin- 
guished. Post-mortem  examination  showed  commenc- 
ing plastic  exudation  like  thin  fluid  glue,  moistening  the 
pleuras,  and  in  some  places  filaments  of  false  membrane 
could  be  raised  and  separated  from  the  pleura,  showing 
that  so  early  had  organization  commenced.  In  all 
these  cases  of  the  cows  the  proof  was  complete.  The 
rales  always  indicated  adhesions,  and  when  there  were 
no  adhesions  there  were  no  rales. 

Accepting,  then,  the  evidence  of  rales,  as  proof  of 
inter-pleural  plastic  exudation  we  are  enabled  to  treat 
these  cases  commensurate  with  their  gravity  and  at  the 
initial  stage,  when  success  is  best  attainable. 

The  physical  signs  of  rales  must  be  searched  for  with 
earnest  attention,  in  any  case  where  they  are  suspected, 
and  when  they  are  discovered,  the  side  in  which  they 
are  should  be  supported  and  restrained  from  movement 
by  adhesive  plaster  extending  from  the  spine  around, 
to  the  sternum.  The  porous  plaster  is  best,  as  it  is 
elastic,  and  allows  auscultation  and  the  application  of 
spirits  of  turpentine,  should  it  be  deemed  necessary. 
Then  should  be  considered  and  determined  the 
weighty  question,  what  is  the  best  course  to  be  foL 
lowed  in  treatment.  If  prompt  and  energetic  measures 
are  decided  upon,  no  time  should  be  lost  in  putting 
them  in  force,  that  heavy  blows  may  be  at  the  begin- 
ning, not  to  be  repeated,  when  the  patient's  strength  is 
well-nigh  exhausted.  Everything  afterwards  should 
be  support  and  building  up,  and  mostly  by  assimilable 
food  of  which  milk  is  the  type. 


132  DISEASES   OF  THE   HEART  AND   LUNGg. 


VIII. 

Cardiac   Murmurs. 

Before  we  can  properly  appreciate  the  significance 
of  cardiac  murmurs  we  must  be  able  to  demonstrate 
the  natural  sounds  of  the  heart,  or,  by  induction,  to  ap- 
proach so  nearly  to  demonstration  that  exact  experiment 
will  scarcely  be  necessary  to  make  the  truth  more 
plain. 

We  propose,  also,  to  consider  the  human  chest  as  an 
acoustic  instrument,  a  sound-bearing  and  multiplying 
chamber,  as  well  as  to  dispose  of  all  ephemeral  mur- 
murs, preliminary  to  entering  into  the  discussion  of  the 
philosophy  of  diseased  or  structural  murmurs. 

The  sounds  of  the  heart  are  two,  the  first  long  and 
the  second  short ;  the  periods  of  silence  or  rest  are  also 
two,  the  first  short  and  the  second  long. 

The  first  sound  is  long,  commencing  with  a  low  moan, 
growing  louder  and  rising  in  pitch  as  it  approaches  the 
ear,  it  ends  with  and  is  emphasized  by  the  impulse-beat. 
Then  follows  the  short  period  of  silence,  which  is  im- 
mediately interrupted  by  the  second  sound,  which  is 
also  very  short  and  flat  in  character,  and,  lastly,  comes 
the  long  period  of  silence. 

The  first  sound,  and  the  second  period  of  silence,  in 
a  healthy  heart  beating  deliberately,  take  up  much  the 
greater  part  of  the  time  in  the  round  necessary  to  com- 
plete the  act  of  impelling  the  blood  into  the  arterial 
system. 

Physiologists  are  not  agreed  as  to  the  mechanism  of 
the  first  sound.     On  the  short  period  of  silence,  the 


CARDIAC   MURMURS. 


133 


second  sound,  and  the  long  period  of  silence,  there  is 
no  controversy.  It  has  been  proved  by  direct  experi- 
ment that  the  second  sound  is  caused  by  the  sudden 
closing  of  the  semilunar  valves  by  the  return  shock  of 
blood.  A  little  hook  passed  into  the  aorta  may  hold 
up  a  curtain  of  the  valve,  when  the  sound  will  be  absent. 
It  is  also  absent  when  disease  has  incapacitated  the 
valve.  The  short  period  of  silence  and  the  long  period 
of  silence  are  made  long  and  short  by  the  second 
sound  dividing  the  period  which  elapses  from  the  time 
when  the  heart  ceases  to  contract  till  it  commences 
again. 

The  heart  has  one  period  of  action  and  one  of  repose. 
This,  really,  is  all  the  heart  has  to  do  with  it.  The 
second  sound  is  formed  independently  of  the  heart 
by  the  return  flow  of  blood  in  the  aorta  against  the 
semilunar  valve,  dividing  the  period  of  the  heart's  rest 
into  two  unequal  parts.  I  shall  not  attempt  to  contro- 
vert the  theory  of  active  dilatation  of  the  heart.  I  only 
desire  to  keep  the  simple  fact  clear  before  the  mind 
that  the  heart  acts,  and  then  rests,  agreeing  with  the 
law  that  muscular  action  or  contraction  is  ahvays  fol- 
lowed by  relaxation,  and  it  would  be  singular  if  nature 
should  make  an  exception  in  so  important  a  muscle  as 
the  heart. 

THE   FIRST   SOUND. 

The  mechanism  of  the  first  sound  is  still  sub-judice. 
If  the  difficulties  environing  this  subject  were  swept 
out  of  the  way,  and  the  cause  of  the  first  sound  were 
made  plain  and  convincing,  it  would  lift  the  unsatisfac- 
tory points  of  cardiac  murmurs  from  the  obscurity  in 
which  they  have  so  long  been  enveloped,  and  place  them 
in  a  clear  light. 

The  majority  of  writers  on  cardiac  sounds  give  pro^  • 


134  DISEASES   OF  THE  HEART  AND   LUNGS. 

minence  to  three  different  theories.  First,  that  of  the 
friction  of  the  blood  in  its  motion  within  the  ventricle 
and  in  its  passage  into  the  aorta.  Second,  that  of  the 
muscular  contraction  of  the  heart  itself  causing  sound. 
This  theory  is  based  on  the  discovery  of  Dr.  Wollaston, 
published  in  the  "  Philosophical  Transactions  of  Great 
Britain"  in  1 8  lo,  of  the  fact  that  muscular  contractions 
cause  sonorous  vibrations.  Third,  that  of  the  vibrations 
of  the  mitral  valve  caused  by  its  closure  and  tension 
and  the  forcing  and  rushing  blood. 

There  are  other  theories  that  scarcely  need  to  be 
noticed,  as  they  fail  to  satisfy  any  acoustic  law. 

Some,  recognizing  the  possibility  of  each  of  the  three 
causes  mentioned  producing  sound,  have  believed,  as 
the  first  sound  is  evidently  composite,  that  it  is  the  re- 
sult of  all  three. 

This  was  Dr.  Cammann's  opinion,  and  it  has  a  greater 
weight  of  probability  and  more  proof  than  either  theory 
alone. 

It  is  clear,  however,  that  the  cause  of  the  first  sound 
must  be  in  full  agreement  with  acoustic  law.  Let  us 
see  if  these  separate  theories  agree  equally  with  the  facts 
and  the  law,  or  if  a  combination  of  these  theoretical 
causes  can  produce  the  first  sound. 

The  friction  of  the  blood,  in  its  motion  within  the 
ventricle  and  in  its  passage  into  the  aorta,  we  can  im- 
agine could  produce  sound  ;  yet  in  a  state  of  health, 
that  friction  must  be  of  minimum  amount,  for  nature 
does  not  create  obstacles  in  her  own  way.  But  if  sound 
f  lom  this  cause  could  be  heard  at  all,  it  would  be  en- 
tirely different  from  what  we  actually  hear.  Blood  in 
motion  in  a  tube  or  vessel  of  irregular  calibre  would 
produce  a  rushing  tube  friction  sound.  It  would  not 
be  vocal,  nor  musical,  and  would  have  no  quality  like 
that  of  the  first  sound,  and  therefore  must  be  excluded. 


CARDIAC   MURMURS.  135 

Contracting  muscle  undoubtedly  produces  sound, 
but  it  passes  no  sound  vibrations  into  the  air.  In  order 
to  hear  the  vibrations  of  contracting  muscle,  it  is  neces- 
sary that  a  sonorous  body  should  convey  them  to  the 
ear. 

The  sound  is  of  very  low  note,  the  lowest  that  can  be 
made  by  a  piano  string,  having  about  thirty-two  vibra- 
tions in  a  second. 

Dr.  Wollaston  called  the  sound  a  susurrus,  that  is,  a 
muttering  sound,  and  likened  it  to  the  sound  of  a  car- 
riage at  night  in  a  distant  street  driven  rapidly  over 
block  pavement. 

Any  one  can  hear  it  by  placing  his  thumbs  in  his  ears 
and  resting  his  elbows  on  a  table,  or  by  closing  the 
teeth  tightly  together,  when  all  is  still  at  night,  with 
the  head  resting  on  the  pillow. 

This  theory  was  the  first  that  was  offered  to  explain 
the  first  sound.  But  it  is  unlike  it,  having  but  one  low 
note,  while  the  natural  first  sound  runs  from  the  lower 
to  the  higher  in  regular  gradation. 

The  third  theory  advanced,  the  vibration  of  the 
tense  mitral  valve  in  the  presence  of  rushing  blood, 
has  greater  probability,  for  it  is  based  on  acoustic  truth. 

But  the  simple  closure  of  the  valve  as  an  act  does 
not  cause  the  sound,  nor  any  part  of  it ;  it  merely  pre- 
pares the  way.  The  valve  being  made  tense  is  fitted  to 
receive  and  reproduce  vibrations  brought  to  it — as  we 
shall  explain  presently — and  of  passing  these  sonorous 
vibrations  into  the  air,  so  that  they  may  be  heard  without 
placing  the  ear  in  contact  with  the  vibrating  body. 
And  yet  this,  without  a  more  active  cause  added,  does 
not  account  for  the  first  sound.  The  first  sound  com- 
mences with  the  low  pitch  of  a  muscular  susurrus ;  it  is 
musical  in  character,  which  a  fluid  friction  sound  is  not. 
Again,  the  tense  mitral  valve,  resisting  forcing,  rushing 


136  DISEASES   OF  THE   HEART  AND   LUNGS. 

blood,  would  not  of  itself  originate  sound  of  the  char- 
acter which  we  hear ;  another  sound-producing  element 
is  necessary  to  account  for  the  low  note  gradually  run- 
ning up  to  higher  pitch,  like  the  string  of  a  musical  in- 
strument having  its  tension  gradually  increased  by  the 
tuner  while  it  is  vibrating. 

Failing  to  be  satisfied  with  either  of  the  three  reasons 
considered,  or  in  their  combination,  because  they  do 
acoustically  nor  exactly  demonstrate  the  first  sound,  let 
us  examine  the  heart  anew,  and  see  if  there  belong  to 
it  any  other  sound-making  apparatus  that  will  fully  ex- 
plain, physically  and  acoustically,  all  the  pecuharities 
of  the  first  sound. 

We  naturally  give  our  attention  first  to  the  interior 
of  the  ventricle,  and  we  find  there  rough  walls  strength- 
ened by  fleshy  colums,  to  which  are  attached  tendinous 
strings  running  athwart  the  ventricular  cavity  to  be  at- 
tached to  the  mitral  valve.  Their  object  is  to  hold  the 
valve  from  being  forced  from  its  integrity,  and  the  con- 
traction of  the  ventricular  walls,  with  the  columnse  car- 
nese  and  musculi  papillares,  are  so  beautifully  contrived 
that  exact  coaptation  is  always  perfectly  maintained,  so 
long  as  the  valve  is  sufficient,  no  matter  what  function- 
al disturbance  or  emotional  excitement  or  other  condi- 
tions may  occur. 

The  valve  is  thin  and  strong,  and  when  tense  is  ca- 
pable of  reproducing  and  multiplying  vibrations  con- 
veyed to  it  of  a  loud  and  sonorous  character,  though 
not  originating  them.  The  union  of  the  chordas  tendi- 
nese  with  the  valve  is  an  apparatus  quite  competent  to 
produce  all  the  characteristics  of  the  first  sound  and  to 
demonstrate  it  acoustically. 

These  tendinous  strings,  stretched  across  the  cavity 
of  the  ventricle  and  rendered  tense  by  muscular  con- 
traction, are  the  very  type  of  a  sound-producing  instru- 


CARDIAC   MURMURS.  1 37 

merit.  The  rushing  of  blood  among  these  cords  must 
cause  vibration,  which,  being  multiplied  and  reproduced 
in  the  tense  mitral  valve,  are  readily  passed  into  the  air 
and  heard  without  the  chest  wall.  It  seems  strange 
that  auscultators  should  generally  have  overlooked  the 
chordae  tendinese  as  the  main  instrument  in  the  produc- 
tion of  the  first  sound.  We  might  as  well  attempt  to 
account  for  the  sound  of  the  violin  without  the  strings 
as  for  the  first  sound  without  the  chordae  tendineae. 

Let  us  return  to  the  study  of  the  beautiful  mechanism 
of  the  first  sound,  and  suppose  the  ventricle  has  been 
filled  in  the  natural  way — the  relaxed  muscular  tissue  of 
the  heart  has  allowed  the  blood,  welling  up  into  the  au- 
ricle, to  flow  freely  into  the  ventricle  through  the  open 
auriculo-ventricular  opening,  till  it  has  floated  the  mit- 
ral valve  up  to  its  position,  closing,  but  without  force, 
the  auriculo-ventricular  opening,  the  heart  remaining 
passive,  being  dilated  by  the  flow  of  blood  only.  But, 
in  due  course,  the  auricle  also  becoming  filled  is  stim- 
ulated to  contract,  which  it  does,  and  sends  a  wave 
of  impulsion  into  the  already  filled  ventricle,  which,  on 
the  principle  of  the  hydrostatic  press,  produces  equal 
pressure  on  every  part  of  the  ventricular  wall,  which 
the  ventricle  acknowledging  as  its  proper  stimulus,  im- 
mediately contracts,  instantly  closing  the  mitral  valve, 
making  tense  the  chordae  tendineae,  and  sending  the 
blood  in  its  arterial  course.  The  motion  of  contraction 
passes  from  the  auricle  downwards,  and  runs  along  the 
ventricular  wall,  and  through  the  columnae  carnese,  ex- 
actly adjusting  the  tension  of  the  chordae  tendineae,  so 
that  the  mitral  valve  is  kept  in  perfect  coaptation,  resist- 
ing the  mighty  force  of  the  contracting  heart,  not  one 
drop  of  blood  being  regurgitated,  but  all  is  hurled  on- 
ward in  its  course.  The  resilient  aorta  sends  back  the 
column  of  blood  against  the  semilunar  valve,  closing  it 


138  DISEASES   OF  THE   HEART  AND   LUNGS. 

with  a  shock,  and  the  heart,  exhausted,  as  it  were,  by 
the  tremendous  effort,  lies  relaxed  and  resting,  waiting- 
to  perform  the  next  beat  in  the  same  way. 

Now,  let  us  consider  the  character  of  the  sound 
caused  by  the  heart's  contraction.  It  commences  in 
a  low  moan,  rising  in  pitch,  and  approaching  the  ear 
as  it  progresses,  and  ends  with  the  impulse  beat. 

The  acoustic  laws  concerned  in  this  sound  are  in 
beautiful  harmony  with  the  mechanism.  At  the  com- 
mencement of  the  sound  the  ventricle  is  full  of  blood, 
and  the  contraction  makes  tense  valve,  chordae  tendi- 
neas,  columnae  carneas,  and  ventricular  walls  ;  the  rush- 
ing blood  has  not  yet  attained  its  maximum  velocity, 
and  the  upper  chordae,  which  are  the  more  tense,  vi- 
brate with  the  motion  of  the  blood  slowly,  and  the  valve 
reproduces  and  multiplies  the  vibrations,  and  the  drum- 
like note  is  the  result.  But  as  the  tension  of  the  chor- 
dae increases  emptying  the  ventricle,  the  sound  agrees 
with  the  facts  and  the  acoustic  conditions,  and  becomes 
louder,  nearer,  and  raised  in  pitch  to  the  end. 

No  other  theory  but  this  accounts  for  the  character 
and  quality  of  the  first  sound,  that  harmonious  note  of 
nature,  the  song  of  health,  into  which,  if  jarring  discord 
be  introduced,  it  tells  of  functional  disturbance  or  struc- 
tural change ;  and  the  diligent  and  enlightened  study 
of  the  discord  will  lead  us  almost  unerringly  to  the  full 
knowledge  of  the  cause. 

In  our  study  of  cardiac  murmurs  we  will  have  fre- 
quent occasion  to  make  reference  to  the  "  chordae  tendi- 
neae  and  mitral  valve  theory"  of  the  first  sound,  which 
is  based  on  acoustic  law,  and  which  is  as  perfect  a 
demonstration  as  we  can  have  or  expect  to  have. 

THE   HUMAN   CHEST  AS  AN  ACOUSTIC   INSTRUMENT. 

The  human  chest  is  an  admirable  instrument  for  mul- 


CARDIAC  MURMURS.  1 39 

tiplying  and  reproducing  sound.  It  is  in  the  form  of  a 
truncated  cone.  Behind,  the  spinal  column  and  the 
firm  articulation  of  the  ribs  make  a  basic  sounding- 
board.  In  front,  the  sternum  attached  by  flexible  car- 
tilages to  the  ribs,  allowing  of  considerable  motion,  acts 
as  a  counter-sounding-board,  which  may  be  brought 
nearer  or  removed  further,  and  adjusted  to  the  exact 
position  for  producing  just  the  amount  or  volume  of 
sound  required.  Below,  where  expansion  may  be  most 
required,  we  find  its  capacity  greatest,  while  above, 
where  form  alone  is  necessary,  it  is  almost  immovable. 
Then,  the  diaphragm  closing  the  lower  part  of  the 
chest  has  great  latitude  of  motion,  and  can  increase  or 
diminish  the  sound  capacity  of  the  chest  at  will.  It  is 
thin  and  tendinous,  and  may  be  fixed  in  tension  high 
up  in  the  chest,  or  low  down,  just  as  may  be  required 
for  the  purpose  of  forming,  increasing,  or  diminishing 
sound. 

Man  has  not  invented  and  may  not  construct  a 
musical  instrument  of  such  varied  applicability  and 
such  marvellous  power.  Ventriloquism  is  but  the  in- 
genious use  of  this  power,  for  all  its  remarkable  sound 
deceptions  depend  upon  the  educated  diaphragm,  modi- 
fying the  quality  of  the  sound  of  the  voice.  Song  and 
speech  depend  on  the  perfection  of  the  human  chest  as 
an  acoustic  instrument  for  their  power  to  enchant  us 
with  melody  or  to  astonish  us  with  the  forcible  expres- 
sion of  thought.  The  violin,  the  most  perfect  of  hu- 
man instruments,  is  formed  on  the  model  of  the  human 
chest — it  has  its  two  sounding-boards,  one  at  the  back 
and  one  in  front,  and  it  has  sides  and  ribs.  Yet  it  has 
no  flexible  cartilages  or  ribs;  the  anterior  sounding- 
board  cannot  be  brought  nearer  or  removed  further, 
and  it  has  no  self-adjusting  diaphragm ;  and  we  may 
well  deem  it  beyond  the  power  of  man  to  construct  an 


I40  DISEASES   OF  THE  HEART  AND   LUNGS. 

instrument  of  equal  capacity  with  the  human  chest  out 
of  unsentient  materials.  The  violin  is  but  the  analogy 
of  the  human  chest.  The  vibrations  of  the  vocal  cords, 
or  the  strings  of  the  violin,  are  reproduced  and  multi- 
plied indefinitely  in  the  sound  chamber  of  the  human 
chest  or  the  violin ;  they  would  have  no  volume,  no 
reverberation,  no  timbre^  removed  from  the  acoustic 
instrument.  Let  the  string  be  attached  to  a  non-sono- 
rous body  and  it  will  vibrate  as  well,  and  the  pitch  will 
be  according  to  the  rapidity  of  the  vibrations,  but  the 
sound  will  have  no  quality  above  that  of  a  child's  toy. 
The  volume  and  quality  of  sound  do  not  depend  upon 
the  vibrations  of  the  string,  but  upon  the  reproducing 
and  multiplying  instrument  to  which  it  is  attached. 
Let  the  instrument  be  ever  so  little  injured  in  its 
acoustic  conditions,  the  alteration  in  the  volume  and 
quality  of  sound  will  measure  the  injury.  Place  a  non- 
vibrating  body  upon  the  violin,  or  pour  sand  or  shot 
or  water  into  it,  and  its  power  of  reproducing  and  mul- 
tiplying sound  will  be  notably  impaired,  and  the  same 
is  true  of  the  human  chest. 

The  lungs  are  constantly  filled  with  air,  dilating 
every  air  sac,  which  by  active  resistance  and  forcible 
contraction  compresses  the  residual  air,  increasing  its 
sonorous  capacity ;  whilst  the  convective  air-tubes  con- 
vey the  sounds,  like  speaking-tubes,  in  every  direction. 
This  completes  the  perfection  of  the  human  chest  as  a 
musical  or  acoustical  instrument. 

Emphysema,  or  consolidation  of  the  lung  from  any 
cause,  or  an  enlarged  heart,  or  an  aneurism,  or  a  tumor, 
or  pleural  effusion,  may  impair  the  acoustic  qualities  of 
the  chest ;  and  consequently  the  study  of  this  subject 
is  one  of  great  importance  to  the  auscultator,  and  this 
is  especially  true  in  regard  to  cardiac  murmurs. 

In  the  rapid  rhythm  of  the  heart's  action  a  murmur 


CARDIAC   MURMURS.  t4t 

may  appear  but  feeble  to  the  unpractised  ear,  and  when 
the  heart  becomes  irregular  and  tumultuous,  it  may  be- 
come difficult  even  for  the  expert  to  read  its  entire  sig- 
nificance, but  should  pneumonia  with  consolidation  or 
pleural  effusion  occur,  all  the  murmurs  would  be  en- 
feebled or  disappear  altogether. 

I  have  known  a  loud  double  murmur  denoting  ob- 
struction at  the  aortic  orifice  and  incapacity  of  the  aor- 
tic valve,  to  so  diminish  in  intensity  during  an  attack  of 
pneumonia  as  to  be  scarcely  heard,  and,  remembering 
this  acoustic  fact,  I  passed  my  ear  to  the  back  part  of 
the  chest,  and  found  to  be  true,  what  I  had  suspected, 
that  consolidation  had  taken  place.  In  this  case  the 
pulse,  usually  about  50  in  a  minute,  was  not  increased 
above  80,  and  was  not  diminished  in  force. 

Pneumonia  and  pleuritis  are  not  unfrequent  compli- 
cations of  cardiac  disease,  and  a  cardiac  murmur  sud- 
denly diminishing  in  intensity,  or  disappearing  alto- 
gether, may  direct  the  attention  and  assist  in  making 
out  a  correct  diagnosis. 

The  philosophy  of  this  novel  and  interesting  acoustic 
physical  sign  may  be  demonstrated  by  placing  a  watch 
or  a  small  music-box  within  a  sound  chamber  like  a 
violin  or  violoncello,  taking  care  that  it  shall  not  touch 
the  walls  of  the  chamber  nor  be  attached  to  them  in 
any  way  which  might  convey  direct  vibrations,  and 
then  to  listen  with  the  ear  or  a  stethoscope  against  the 
outside  of  the  chamber,  and  to  notice  the  clearness  and 
distinctness  with  which  even  the  lower  notes  can  be 
heard,  and  then,  while  still  listening,  let  an  assistant 
pour  water  or  sand  into  the  instrument,  and  then 
to  notice  the  gradual  diminishing  of  the  intensity  of 
sounds  until  they  grow  very  feeble  or  disappear  en- 
tirely, especially  the  lower  notes. 

With  this  brief  consideration  of  these  two  preliminary 


142  DISEASES   OF  THE   HEART  AND   LUNGS. 

subjects,  some  knowledge  of  which  I  deem  absolutely 
essential  to  a  proper  understanding-  of  the  diseased 
heart  sounds,  we  may  turn  our  attention  to 

CARDIAC   MURMURS. 

Cardiac  murmurs  may  be  divided  into  those  which 
are  signs  of  functional  disturbance  and  those  which  de- 
note structural  disease  of  the  heart. 

Functional  murmurs  may  be  divided  into  three  kinds, 
those  depending  upon  anaemia,  those  depending  upon 
plethora,  and  those  depending  upon  disease  in  some 
other  organ  acting  through  sympathy. 

The  anasmic  murmur  is  generally  easy  of  diagnosis. 
The  marked  anasmic  condition  will  direct  the  attention 
from  the  first.  The  murmur  is  loud  and  diffused,  heard 
over  the  base  of  the  heart,  and  is  carried  thence  in  every 
direction  over  the  chest.  It  is  increased  by  slight  ex- 
ertion, and  has  no  point  of  particular  intensity,  except 
at  the  apex-beat,  which  distinguishes  it  from  a  struc- 
tural murmur.  It  is  very  noisy,  and  may  mislead  the 
inexperienced. 

The  plethoric  murmur  may  be  heard  where  there  is 
a  full  habit  with  an  excitable  condition  of  the  nervous 
system.  It  is  most  frequently  heard  in  pregnancy,  and 
may,  sometimes,  assist  in  making  a  diagnosis  of  that 
condition.  The  murmur  is  heard  over  the  base  of  the 
heart,  as  are  all  functional  murmurs,  but  is  not  loud  like 
the  anasmic  murmur,  neither  is  it  heard  over  distant 
parts  of  the  chest ;  it  is  heard  alone  in  the  region  of  the 
heart,  and  has  a  low,  muffled  character. 

A  sympathetic  functional  murmur  has  its  cause  in 
disease  of  some  other  organ,  as  the  brain,  stomach,  or 
uterus,  and  is  not  necessarily  accompanied  with  either 
anasmia  or  plethora,  and  is  caused  wholly  by  an  excited 
State  of  the  nervous  system. 


CARDIAC   MURMURS.  143 

All  functional  murmurs  are  somewhat  intermittent, 
and  always  pass  away  with  the  removal  of  the  cause. 
They  all  have  their  site  within  the  ventricle,  and  are 
owing,  mainly,  to  irregular  contraction  of  the  columnas 
carnae,  the  musculi  papillares  and  the  ventricular  wall, 
bringing  the  chordse  tendinese  into  irregular  tension, 
and  causing  discord  in  the  natural  first  sound. 

The  varying  conditions  of  the  blood  account  for  the 
differences  in  the  character  of  the  three  varieties  of 
functional  murmurs.  In  anasmia  the  blood-vessels  are 
not  distended,  the  general  acoustic  qualities  of  the 
chest  are  increased,  and  the  blood  rushes  along,  carry- 
ing the  murmur  far  into  the  blood-vessels,  from  which 
sonorous  vibrations  are  past  into  every  part  of  the 
chest  wall.  In  plethoric  murmur  the  acoustic  condi- 
tions are  decreased,  and  the  murmur  is  carried  but  a 
short  distance  from  the  heart ;  and  in  functional  mur- 
murs from  extrinsic  disease,  the  conditions  of  the  chest 
remaining  natural,  the  murmur  will  not  be  so  loud,  nor 
will  it  be  carried  so  far,  as  in  angemia,  and  yet  it  will  be 
further  than  in  plethora. 

There  are  some  functional  murmurs  that  deserve  par- 
ticular attention-.  One  is  the  systolic  murmur  heard  in 
inflammatory  rheumatism.  It  may  cause  needless  alarm 
to  those  not  fully  apprehending  its  meaning,  yet  it  is  a 
warning  to  the  intelligent  physician  that  will  direct  his 
watchful  attention  to  the  heart.  It  is  an  Intraventricu- 
lar murmur,  and  we  are  enabled  by  the  rules  we  have 
laid  down  to  diagnosticate  it  differentially  from  an  or- 
ganic murmur.  It  is  of  harsh  character,  heard  over  the 
base  of  the  heart,  but  not  with  maximum  intensity  at 
the  apex-beat,  nor  is  it  heard  with  particular  emphasis 
at  the  aortic  orifice,  or  at  the  place  where  the  aorta 
emerges  beneath  the  sternum,  nor  under  the  clavicle. 
It  is  heard  in  the  direction  of  the  current  of  blood,  but 


144  DISEASES   OF  THE   HEART  ANb   LUNG^. 

the  sound  is  of  a  diffused  character  hke  other  functional 
murmurs.  Its  character  sometimes  runs  quickly  into 
one  denoting  deposits  of  lymph  upon  the  valves.  If 
the  murmur  becomes  suddenly  distinct  over  the  aortic 
valve,  and  is  heard  emphatically  at,  or  near,  the  carti- 
lage of  the  fourth  rib  of  the  right  side  and  under  the 
right  clavicle,  and  on  either  side  of  the  spine  from  the 
third  to  the  sixth  vertebrse  behind,  we  know  deposit 
has  taken  place  at  the  aortic  orifice,  or  if  the  murmur 
assumes  maximum  intensity  at  the  apex-beat  and  is  of 
rasping  character,  we  know  that  there  has  been  deposit 
upon  the  mitral  valve.  This  murmur  has  given  rise  to 
the  opinion  that  acute  articular  rheumatism  always 
produces  some  damage  to  the  heart,  which  is  not  quite 
correct,  for  the  murmur  frequently  subsides  and  passes 
away  with  the  rheumatism,  proving  that  it  was  only  a 
functional  murmur.  A  careful  study  of  it  affords  a  val- 
uable index  as  to  the  treatment  best  to  pursue  to  pre- 
vent damage  to  the  heart,  or  when  we  can  safely  leave 
the  ordinary  treatment  to  take  its  course,  knowing  that 
the  murmur  will  disappear  as  the  rheumatism  gets  well. 
Its  cause  is  probably  due  to  spasmodic  contraction  of 
the  muscles  of  the  heart  from  nervous  excitability  of  the 
endocardium,  due  to  the  irritating  quality  of  the  blood. 

Adhesions  of  the  lungs  to  the  chest  wall  to  the  medi- 
astinum, and  more  especially  to  the  pericardial  pleura, 
as  well  as  pericardial  adhesions  to  the  heart,  also  pro- 
duce murmurs,  and  the  murmurs  continue  so  long  as 
the  adhesions  may  influence  the  symmetrical  contrac- 
tion of  the  ventricular  wall.  These  murmurs  are  apt 
to  mislead  the  practitioner  into  making  a  false  diagnosis, 
but  they  have  no  important  significance,  for  when  the 
adhesions  lengthen  sufhciently  the  murmurs  will  disap- 
pear. 

There  is  also  a  functional  murmur,  associated  with 


CARDIAC   MtJRMUkS.  .  '      ,145 

chorea,  which  has  been  considered  as  the  result  ot  car- 
diac disease.  Cardiac  disease  may  be  complicated  with 
chorea,  but  that  is  exceptional ;  the  murmur  of  chorea 
is  ephemeral,  like  all  functional  murmurs,  and  disap- 
pears with  the  disease  that  causes  iti  There  is  a  pecu- 
liarity about  the  murmur  of  chorea  that  has  given  rise 
to  the  belief  with  some  that  it  is  caused  by  mitral  re^ 
gurgitation,  because  this  murmur  is  emphasized  at  the 
apex-beat.  In  the  proper  place  we  will  endeavor  to 
show  that  the  apex-beat  murmur  is  never  a  sign  of 
mitral  regurgitation.  But  it  is  a  sign,  if  that  were 
necessary  in  this  disease,  of  unusual  and  violently  irreg- 
ular contraction  of  muscular  tissue  of  the  heart,  that 
the  chordae  tendineae  are  so  irregularly  and  so  forcibly 
brought  into  tension  that  the  murmur  is  conveyed  in 
the  muscular  tissue  of  the  heart  to  the  chest  wall,  and 
of  course  will  be  emphasized  at  the  apex-beat.  Re- 
gurgitation through  the  mitral  valve  never  takes  place 
except  from  insufficiency. 

CARDIAC  MURMURS— ORGANIC. 

The  left  side,  or  the  left  heart,  being  mostly  in  front 
and  near  the  chest-wall  and  accessible  to  the  ear,  will 
be  considered  when  we  speak  of  cardiac  murmurs. 
This  is  eminently  proper,  as  the  left  heart  performs  the 
important  office  of  impelling  the  blood  into  the  system, 
has  much  greater  muscular  development,  and  is  much 
more  liable  to  organic  disease  than  the  right  heart, 
and  as  they  act  in  perfect  synchronism  in  health, 
what  is  said  of  the  left  will  be  true  of  the  right,  with, 
such  exceptions  as  will  be  noted  subsequently.  The 
left  heart,  like  the  right,  has  an  auricle  and  a  ventricle, 
two  valves,  the  aortic  semilunar  and  the  mitral  auri- 
culo-ventricular  valve,  and  each  valve  may  have  two 
murmurs,  the  dual  character  of  the  heart  always  being 


146  DISEASES   OF  THE   HEART  AND   LUNGS. 

maintained.  The  aortic  valve  may  have  two  murmurs, 
the  aortic  obstructive  systolic  and  the  aortic  regurgi- 
tant diastolic. 

The  aortic  systolic  obstructive  murmur  is  caused  by 
some  impediment  to  the  flow  of  blood  at  the  aortic  ori- 
fice, which  may  be  deposits  of  lymph,  or  warts,  or  ex- 
crescences, or  it  may  be  what  is  called  ossification — ■ 
calcareous  deposits  at  the  aortic  orifice  or  in  the  cur- 
tains of  the  valve.  It  must  be  something  that  will 
throw  the  current  of  blood  into  unusual  vibration,  and 
must  agree  acoustically  with  the  physical  facts.  The 
murmur,  froni  the  manner  of  its  formation,  must  have 
certain  definite  characteristics  that  will  distinguish  it 
from  other  murmurs ;  it  must  agree  with  the  mechanism 
of  its  cause.  We  must  insist  upon  this  fundamental 
truth  in  regard  to  all  the  murmurs  of  the  heart ;  the 
character  of  the  murmur  is  an  indication  of  the  cause. 
In  health  the  blood  flows  through  the  aortic  orifice 
without  murmur,  the  sounds  of  the  heart  are  heard,  if 
the  ear  be  placed  over  the  aortic  valve,  but  nothing 
else.  But  let  a  deposit  of  lymph  take  place  upon  the 
valve,  and  notice  of  the  fact  will  immediately  be  given 
by  the  murmur.  What  will  be  the  character  of  that 
murmur  ?  This  we  are  able  to  demonstrate :  fluid 
forced  through  a  tube  of  equable  calibre  will  cause  no 
murmur,  but  if  obstruction  at  a  certain  point  be  caused 
by  pressure  upon  the  tube,  or  otherwise,  a  murmur  will 
be  the  immediate  result.  The  character  and  quality  of 
this  murmur  must  be,  from  the  identity  of  the  cause, 
the  same  as  is  heard  when  there  is  obstruction  at  the 
aortic  orifice  ;  it  will  be  a  fluid  friction  sound,  and  have 
a  rushing  character.  When  hypertrophy  has  taken 
place,  the  murmur  will  be  altered  or  disguised  by  a 
vocal  element  of  sound,  which  will  be  more  particularly 
described  when  we  come  to  speak  of  the  mitral  non- 


CARDIAC   MURMUR^.  14/ 

i'egurgitant  murmur.  The  normal  character  of  this 
murmur  is  only  heard  for  a  short  time,  for  as  soon  as 
hypertrophy  of  the  ventricle  takes  place  as  a  result  of 
the  obstruction,  the  murmur  heard  will  be  of  a  compos- 
ite character,  for  the  mitral  non-regurgitant  murmur 
will  be  a  part  of  the  sound.  It  is  well  to  keep  this  dis- 
tinctioQ  before  the  mind,  for  the  importance  of  the 
damage  done  is  not  measured  by  the  noisy  element  of 
the  intraventricular  murmur,  but  rather  by  the  charac- 
ter of  the  murmur  formed  at  the  aortic  orifice.  If  the 
obstruction  be  but  little,  the  murmur  will  be  short  in 
duration,  not  of  high  pitch,  and  will  be  heard  at  the 
same  moment  with  the  first  sound,  and  will  be  of  the 
character  of  fluid  friction.  If  the  obstruction  be  con- 
siderable, the  murmur  will  be  prolonged  and  of  higher 
pitch,  and  will  be  more  easily  recognized  by  its  dissim- 
ilarity from  the  natural  first  sound,  especially  when 
discord  has  been  introduced  by  hypertrophy  or  by  dis- 
eased mitral  valve.  This  murmur  may  be  heard  best 
at  certain  points  where  the  column  of  blood  approaches 
the  chest-wall. 

Where  the  aorta  emerges  from  under  the  sternum  on 
the  right  side,  near  or  above  the  cartilage  of  the  fourth 
rib,  will  be  one  of  these  points ;  under  the  clavicle  will 
be  another ;  and  posteriorly  on  either  side  of  the  spine 
from  the  third  to  the  fifth  vertebra,  and  on  the  right 
side  running  down  the  scapula  to  its  lower  angle  are 
diagnostic  points  where  we  may  search  for  this  murmur 
when  we  have  reason  to  fear  the  cause  is  established. 
It  is  rarely  heard  uncompHcated  with  other  murmurs ; 
but  by  experience  the  ear  learns  to  discriminate  and  to 
judge  of  the  amount  of  obstruction  and  the  probable 
damage. 

The  aortic  diastolic  regurgitant  murmur  is  the  second 
murmur  heard  in  connection  with  the  aortic  valve.     It 


148  DISEASES  OF  THE  HEART  AND  LUNGS. 

is  heard  during  the  long  period  of  silence^  and  tvith  or 
immediately  after  the  closure  of  the  semilunar  valve, 
and  is  caused  by  its  insufficiency.  As  the  result  of  dis- 
ease or  by  violence,  an  opening  is  forUied  in  the  valve 
v^hich  allows  a  stream  of  blood  to  be  thrown  back  into 
the  ventricle.  This  murmur  is  uncomplicated,  for  the 
intraventricular  murmurs  are  not  heard  during  the  di- 
astole. It  has  only  one  quality,  that  of  blood  friction, 
and  will  be  long  or  short,  of  raised  or  comparatively  low 
pitch,  according  to  the  size  or  shape  of  the  orifice 
allowing  the  regurgitation.  This  sound  may  be  accu- 
rately imitated  by  forcing  fluid  through  a  syringe,  and 
by  altering  the  aperture  of  the  nozzle  imitates  the  char- 
acteristics of  the  aortic  regurgitant  murmur. 

This  murmur  may  be  'heard,  and  is  most  generally 
heard,  about  half  an  inch  to  an  inch  from  the  aortic 
valve,  in  a  direction  toward  the  apex-beat.  Sometimes 
it  is  heard  as  far  as  to  the  apex-beat,  and  sometimes  it 
is  only  heard  through  the  sternum,  and  some  distance 
from  the  aortic  orifice. 

The  reasons  for  these  variations  depend  upon  the 
direction  given  to  the  stream  of  regurgitated  blood  and 
the  proximity  of  the  heart  to  the  chest  wall. 

This  murmur  generally  appears  in  the  order  of  suc- 
cession. If,  during  an  attack  of  rheumatism,  a  deposit 
of  lymph  occurs  on  the  aortic  valve,  the  murmur  giving 
notice  of  the  fact  will  be  the  obstructive  murmur ;  the 
regurgitant  murmur  will  not  be  heard  at  first,  nor  till 
some  time  afterward,  when  the  plastic  deposit  following 
the  law  governing  these  deposits  will  commence  to  con- 
tract, and  then  when  the  curtains  of  the  valve  can  no 
more  be  brought  into  coaptation,  regurgitation  will  en- 
sue, and  the  diastolic  murmur  will  be  the  sign.  Or  the 
cause  may  be  warts  or  vegetations,  or  the  deposit  of 
calcareous  matter,  or  it  may  be  the  result  of  violence. 


CARDIAC   MURMURS-  I49 

in  which  case  it  would  not  be  preceded  by  the  ob- 
structive  murmur.  This  murmur  is  sometimes  difficult 
to  hear.  The  gentle  rush  of  blood,  when  the  heart's 
action  is  irregular  and  tumultuous,  requires  an  acute 
ear  to  catch  the  sound.  Frequently  the  altered  second 
sound  gives  warning  that  insufficiency  of  the  valve  is 
about  to  take  place.  This  alteration  will  be,  that  while 
the  second  sound  is  more  forcible  than  natural,  it  be- 
gins to  lose  in  clearness,  and  has  a  muffled  character. 

THE   MITRAL  VALVE. 

The  murmurs  connected  with  the  mitral  valve  are 
two ;  the  mitral  regurgitant  and  the  mitral  non-regur- 
gitant  or  the  intraventricular.  They  are  both  systolic 
murmurs.  One  has  its  diagnostic  seat  in  the  posterior 
chest  wall,  and  the  other  in  the  anterior. 

THE   MITRAL  REGURGITANT   SYSTOLIC   MURMUR. 

In  studying  this  murmur  we  must  first  endeavor  clear- 
ly to  understand  the  cause ;  for  the  murmur  when  it  is 
heard,  to  be  truthfully  explained,  must  agree  not  only 
with  the  physical  conditions  of  the  cause,  but  with  acous- 
tic law.  The  cause  is  simply  insufficiency  of  the  mitral 
valve.  From  disease  or  from  violence,  an  opening  has 
been  made  in  the  valve,  and  when  contraction  of  the 
ventricle  takes  place,  and  the  valve  is  made  tense  by 
the  forcing  of  the  blood  and  the  restraint  of  the  chor- 
dae tendinese,  a  stream  of  blood  will  be  violently  rushed 
through  the  opening.  This  will  cause  a  murmur  the 
character  of  which  will  be  determined  by  the  size  and 
form  of  the  aperture. 

It  will  be  a  blood  friction  murmur  complicated  with 
sonorous  vibrations  of  the  chordas  tendi  nnse  of  the 
mitral  valve,  and  will  be  heard  during  the  systole  io 
the  posterior  chest  wall. 


i$0  DISEASES   OF  THE   HEART  AND   LUNGS. 

Regurgitation  through  the  mitral  valve  may  be  from 
congenital  malformation,  but  it  generally  takes  place 
after  the  valve  has  been  damaged  by  disease. 

The  valve  may  be  ruptured  by  violence,  but  this  is  a 
very  unusual  accident.  Or,  dilatation  of  the  auriculo- 
ventricular  orifice  from  degeneration  of  muscle  may 
incapacitate  the  valve,  but  as  a  rule  the  murmur  ap- 
pears some  time  after  a  deposit  of  lymph  has  taken 
place,  or  from  calcareous  deposits. 

The  character  of  the  murmur  is  evidence  of  the  con- 
dition of  the  valve. 

If  the  murmur  be  harsh  and  rasping  as  well  as  having 
the  blood-friction,  rushing  character,  we  are  safe  in 
judging  that  the  valye  has  lost  its  acoustic  quality  of 
reproducing  sound  ;  that  it  is  damaged  by  hardened 
deposits  of  lymph  or  by  calcareous  deposits.  But  the 
fact  should  be  severely  questioned  before  it  is  admitted, 
for  it  is  certain  that  interpleural  adhesions  attached  to 
the  pericardial  sac  restraining  the  heart's  movement 
may  give  rise  to  a  systolic  murmur  all  but  indis- 
tinguishable from  that  of  a  damaged  but  non-regurgi- 
tant  mitral  valve. 

The  murmur  heard  in  front  at  the  apex  beat,  may 
give  notice  of  these  deposits  upon  the  mitral  valve  and 
of  their  character.  This  murmur  is  called  the  mitral 
regurgitant  murmur  by  writers  generally,  but  it  is  never 
a  sign  of  regurgitation,  but  of  deposits  upon  the  valve, 
and  its  presence  will  give  notice  that  regurgitation  may 
take  place,  if  it  have  not  already. 

Where  shall  we  seek  for  the  true  regurgitant  mur- 
mur ?  In  the  first  place  we  must  ascertain  the  direction 
of  the  regurgitated  stream,  for  the  sound  vibrations 
are  carried  along  with  it  and  proceed  in  the  direction 
in  which  it  is  sent. 

If  the  stream  strikes  upon  a  continuous  substance 


CARDIAC   MURMURS.  I5I 

capable  of  transmitting  vibrations,  they  may  be  heard 
in  the  chest  wall.  If  we  suspect  insufficiency  of  the 
mitral  valve,  it  will  become  a  certainty  beyond  cavil,  if 
we  hear  a  blood-friction  sound  between  the  seventh 
and  eighth  vertebras  close  to  their  spines.  It  satisfies 
the  ear  that  the  cause  is  found,  for  it  rushes  into  the 
ear,  as  it  were,  and  has  the  same  character  as  the  aortic- 
regurgitant  murmur,  modified  by  the  mitral  valve  ;  yet 
its  characteristics  will  be  recognized  even  in  the  pres- 
ence of  other  murmurs. 

,  Its  maximum  intensity  is  only  heard  between  the 
seventh  and  eighth  vertebrae,  and  there  the  character 
of  the  sound  is  diagnostic.  It  must  not  be  confounded 
with  the  mitral  non-regurgitant  murmur  which  may 
sometimes  be  heard  at  the  lower  angle  of  the  scapula, 
where  also  the  aortic  regurgitant  is  occasionally  heard. 
The  murmur  may  be  heard  from  the  lower  border  of 
the  fifth  to  the  upper  border  of  the  eighth  vertebrae, 
but  the  characteristic  murmur  which  renders  the  diag- 
nosis certain  is  only  heard  between  the  seventh  and 
eighth  vertebrae ;  and  unless  heard  here  distinctly, 
regurgitation  will  not  be  proven,  notwithstanding  the 
presence  of  other  physical  signs  and  rational  symp- 
toms, which  are  given  by  writers  as  signs  of  mitral 
regurgitation. 

The  anatomical  reasons  why  the  diagnostic  regur- 
gitant murmur  should  be  heard  between  the  seventh 
and  eighth  vertebrae  are,  to  my  mind,  convincing. 

When  Dr.  H.  M.  Sprague,  U.  S.  A.,  was  a  member 
of  the  Examining  Board  in  this  city,  in  1864  and  '5,  I 
requested  him  to  demonstrate  upon  the  cadaver  the 
anatomical  relations  of  the  mitral  valve  and  the  left 
auricle  with  the  organs  between  the  auricle  and  the 
vertebrae,  which  he  did  a  number  of  times,  and  gave 
me  the  following  explanation. 


152  DISEASES   OF  THE  HEART  AND   LUNGS. 

"The  left  auriculo- ventricular  opening  lies  over  the 
seventh  intervertebral  space,  the  left  auricle  lying  over 
the  seventh  vertebrae,  having  the  oesophagus  on  the 
left  and  the  aorta  on  the  right,  in  immediate  relation 
behind.  The  oesophagus  overlaps  the  aorta  somewhat 
in  this  region."  This  is  sufficient  anatomical  proof. 
The  mitral  valve  lies  over  the  seventh  intervertebral 
cartilage,  and  a  regurgitant  stream  of  blood  would  be 
thrown  directly  toward  this  cartilage,  and  the  sound 
vibrations  would  be  continued  through  the  oesophagus, 
aor^a,  and  cartilage  to  the  ear.  The  mitral  valve  is 
near  enough  to  allow  vibrations  to  pass  into  the  seventh 
vertebras  during  regurgitation,  and  also  the  auricle 
lying  upon  it  would  pass  vibrations  into  it.  The  pul- 
monary vein  passing  up  over  the  sixth  vertebrae  would 
pass  vibrations  through  it  to  its  upper  border. 

All  this  will  agree  with  Dr.  Cammann's  description, 
that  the  murmur  may  be  heard  from  the  lower  border 
of  the  fifth  to  the  upper  border  of  the  eighth,  with 
maximum  intensity  and  characteristic  quality  between 
the  seventh  and  eighth  only, 

Bellingham  and  others  describe  the  murmur  heard 
in  front  as  diagnostic  of  mitral  regurgitation,  and  suc- 
ceeding writers  and  lecturers  have  taught  the  same 
doctrine  till  it  has  come  to  be  the  settled  view  of  the 
profession.  Yet  I  may  run  the  risk  of  being  called  a 
^'  setter-forth  of  new  doctrines,"  by  attempting  to  prove 
Dr.  Cammann's  opinion  to  be  correct  and  the  generally 
received  opinion  to  be  in  error. 

In  the  British  and  Foreign  Medico-Chirurgical  Re- 
view of  July,  1861,  there  is  an  article  by  J.  S.  Bristowe, 
M.D.,  Lond.,  F.R.C.P.,  Physician  to  St.  Thomas's 
Hospital,  on  mitral  regurgitation  arising  independently 
of  organic  disease  of  the  valve. 

pr»  Pristo\ve  says  that  he  had  conducted  the  post 


CARDIAC   MURMURS.  1 53 

mortem  examinations  of  medical  cases  at  St.  Thomas's 
Hospital  for  more  than  ten  years.  He  says,  "  It  by  no 
means  infrequently  fell  to  my  lot  to  inspect  cases  of 
reputed  mitral  disease,  in  which  all  the  secondary  effects 
of  that  lesion — pulmonary  apoplexy,  anasarca,  nutmeg- 
liver — were  indisputably  present,  but  in  which  the  heart 
was  found  to  present  but  little  departure  from  the 
healthy  state,  and  in  which  all  the  valvular  structures 
appeared  to  be  perfectly  sound  and  competent.  I  have 
felt  convinced,  for  some  years  past,  that  these  cases 
were  neither  exceptional  nor  rare."  Again  he  says, 
before  detailing  his  six  cases,  "  My  first  object  will  be 
to  prove  the  fact  of  regurgitation  through  the  left 
auriculo-ventricular  orifice  in  certain  cases  in  which 
the  mitral  valve  is  found  to  exhibit  a  perfectly  healthy 
appearance,  and  to  establish  the  frequency  of  its  occur- 
rence, by  detailing  such  well-marked  examples  of  the 
phenomenon  in  question  as  have  occurred  in  the  hos- 
pital during  the  four  years  above  specified."  Dr.  Bris- 
towe's  cases  are  related  with  minuteness,  and  give  not 
only  the  signs  observed  during  life,  but  also  the  post- 
mortem appearances. 

After  detailing  his  cases  he  says,  "  I  have  remarked 
that  it  ma}^  be  regarded  as  an  axiom,  that  the  existence 
of  a  systolic  murmur  at  the  apex  beat  of  the  heart  is  a 
sure  indication  of  incompetence  of  one  or  other  of  the 
auriculo-ventricular  valves,  and  that  so  rarely  is  this 
phenomenon  manifested  in  connection  with  the  right 
side  of  the  organ,  that  it  might  almost,  for  practical 
purposes,  be  accepted  as  the  proof  ot  mitral  incompe- 
tence alone.  This  statement  merely  expresses  the  cur- 
rent doctrine  of  the  day,  a  doctrine  which  no  one  will 
call  in  question,  and  one,  indeed,  which  cannot  be  con- 
troverted without  entirely  upsetting  the  present  well- 
establi3hed  principles  of  cardiac  pathology," 


154  DISEASES   OF  THE   HEART  AND   LUNGS. 

Dr.  Bristowe  states  fairly  the  prevalent  doctrines 
of  the  day,  and  yet  his  cases  prove,  if  they  prove  any- 
thing, that  that  doctrine  is  an  error ;  and  that  the  apex- 
beat  murmur  is  not  a  sign  of  mitral  regurgitation.. 

The  frequent  exceptions  which  Dr.  Bristowe  men- 
tions, where  the  apex-beat  murmur  failed  to  be  a  sign 
of  diseased  mitral  valve,  agrees  with  the  experience  of 
others,  and  completely  invalidates  its  diagnostic  value. 

An  apex-beat  murmur  is  frequently  but  not  always 
associated  with  regurgitation,  and  the  regurgitation 
may  take  place  with  no  murmur  heard  in  front,  and 
the  apex-beat  murmur  is  frequently  present  when  there 
is  no  incompetency,  and  sometimes  when  there  is  no 
disease  even  of  the  valve.  It  would  be  interesting  to 
know  if  in  any  of  Dr.  Bristowe's  cases  the  regurgitant 
murmur  could  have  been  heard  behind  in  its  proper 
place.  In  one  of  the  cases  detailed  it  is  possible  that 
the  dilatation  of  the  auriculo-ventricular  orifice  was 
sufficient  to  allow  regurgitation ;  but  it  seems  to  me 
there  could  not  have  been  in  the  five  others.  As  laid 
down  in  books  and  taught  didactically,  there  are  a 
great  many  more  cases  of  mitral  regurgitation  than 
aortic  regurgitation,  but  the  sign  depended  upon  is 
fallacious.  When  we  come  to  scrutinize  these  cases 
and  apply  the  proper  test  we  find  them  diminish  to  a 
small  number,  much  less  than  the  average  number  of 
aortic  regurgitations.  The  average  number  of  regurgi- 
tations through  the  tricuspid  valve  is  still  less. 

Dr.  Bristowe  also  refers  to  Mr.  Wilkinson  King's 
well  known  paper,  '  On  the  Safety- Valve  Function  in 
the  Right  Ventricle  of  the  Heart'  He  there  attributes 
the  regurgitation  which,  as  a  normal  process,  takes 
place  occasionally  through  the  tricuspid  aperture,  to 
temporary  over-distention  of  the  thin  and  yielding 
ventricular  walls,  and  consequent  displacement  and  in- 


CARDIAC   MURMURS.  1 55 

sufficient  length  of  the  musculi  papillares  and  chordae 
tendineas." 

Dr.  Bristowe,  then,  accepting  Mr.  King's  theory  as 
satisfactory  in  regard  to  the  tricuspid  valve,  reasons 
that  in  dilatation  of  the  left  ventricle  it  would  be  assimi- 
lated in  character  to  the  right,  and  then  the  regurgita- 
tion might  take  place  through  the  mitral  valve.  But  is 
it  ever  true  with  either  the  tricuspid  or  mitral  valve 
that  regurgitation  takes  place  as  a  safety-valve  func- 
tion ?  I  shall  be  slow  to  believe  it.  Are  these  not 
theories  made  necessary  to  explain  the  inconsistency  of 
the  apex-beat  murmur  as  a  sign  of  regurgitation  ?  It 
seems  to  me  Dr.  Bristowe's  article  proves  the  necessity 
of  reviewing  ''the  current  doctrine  of  the  day"  that 
the  apex-beat  murmur  is  a  sign  of  regurgitation 
through  either  the  tricuspid  or  mitral  valves ;  and  I 
present  Dr.  Cammann's  sign  of  a  characteristic  murmur 
heard  between  the  seventh  and  eighth  vertebrae  as  the 
only  sign  that  really  proves  mitral  regurgitation.  This 
sign  is  infallible  when  clearly  made  out.  It  is  possible 
that  regurgitation  may  take  place,  and  this  sign  be 
unheard ;  but  if  so,  the  fact  is  exceptional.  I  have 
never  known  a  case. 

The  frequency  of  regurgitation  through  the  different 
valves  is  the  reverse  of  what  has  usually  been  taught. 
The  possibility  or  probability  of  sudden  death  is  a  sub- 
ject of  alarming  interest  to  the  patient  or  to  his  friends. 
And  for  that  reason  aortic  regurgitation  has  been 
looked  upon  as  a  fearful  omen.  Yet  it  is  Avithin  the 
experience  of  every  physician  who  has  seen  much  prac- 
tice, that  incapacity  of  the  aortic  valve  is  not  incompati- 
ble with  a  long  life.  If  we  reject  the  apex-beat  murmur, 
and  confine  our  diagnosis  of  mitral  regurgitation  to  Dr. 
Cammann's  sign  of  a  characteristic  murmur  between 
the  seventh  and  eighth  vertebras,  agreeing  with  mitraj 


156  DISEASES   OF  THE   HEART  AND   LUNGS. 

insufficiency  as  shown  by  post-mortem  examinations, 
the  relative  frequency  of  these  regurgitations  will  be 
changed,  and  the  aortic  regurgitation  will  be  first  in 
the  order  of  frequency,  the  mitral  next,  and  probably 
the  tricuspid  last  of  all.  I  say  probably,  for  I  cannot 
point  you  to  any  certain,  invariable  sign  of  tricuspid 
regurgitation.  Perhaps  this  alarming  sign  has  been 
wisely  hidden  from  us. 

The  following  statement  is  probably  correct  Inca- 
pacity of  the  aortic  valve  is  of  the  greatest  frequency, 
next  of  the  mitral  third  of  the  tricuspid,  and  of  the  pul- 
monary semilunar  valves  least  of  all,  if  at  all.  I  do  not 
know  of  a  single  well-authenticated  case  of  insufficiency 
of  the  pulmonary  valve  existing  for  any  length  of  time 
during  life. 

The  origin  of  the  manifestations  of  life  are  first  no- 
ticed in  structural  formation. of  the  right  auricle,  and 
there  also  is  noticed  the  last  act  of  expiring  functional 
life.  It  seems  proper,  then,  that  we  should  locate  the 
point  of  greatest  danger  in  the  right  auricle,  and  that 
serious  damage  done  to  the  tricuspid  valve,  involving 
its  integrity,  should  be  attended  with  great  danger. 
With  our  present  knowledge,  it  seems  marvellous  that 
the  heart  should  go  for  so  long  a  time  under  disability, 
and  then,  without  any  new  condition  being  set  up, 
suddenly  to  sulk  and  stop  ;  and  yet  it  is  no  more  sur- 
prising than  that  it  ever  began  to  beat,  or  that  it  con- 
tinues for  years  when  once  begun. 

The  danger  of  the  heart's  suddenly  stopping  is  prob- 
ably greater  when  there  is  extensive  disease  invading 
both  hearts.  But  if  influences  received  through  the 
great  organic  nerve  hurry  the  heart's  action,  while  in- 
fluences received  through  the  pneumogastric  slow  it, 
the  sudden  stopping  may  be  but  a  freak  of  nerve  in- 
fluence. 


CARDIAC   MURMURS.  I57 

THE    MITRAL  NON-RE GURG I TANT. 

Those  who  have  followed  us  in  our  study  of  the 
mechanism  of  the  first  sound  will  readily  comprehend 
what  we  have  to  say  on  this  subject,  in  a  few  words. 
We  have  described  the  first  sound  as  being  the  result 
of  blood  rushing  through  and  among  the  tense  chordae 
tendineae,  and  of  course  throwing  them  into  sonorous 
vibrations,  which  being  reproduced  in  the  tense  mitral 
valve  cause  a  sound  of  a  certain  character.  This  sound 
is  caused  by  a  natural  musical  instrument,  the  heart, 
and  like  a  perfect  artificial  musical  instrument,  discord 
is  proof  of  derangement  either  functional  or  organic.  I 
shall  include  in  my  description  of  the  mitral  non-regur- 
gitant  murmurs,  all  the  murmurs  having  a  cause  in 
the  mitral  valve  or  chordas  tendineae,  whether  func- 
tional or  organic,  whether  owing  to  irregular  contrac- 
tion of  the  walls  of  the  heart  or  columnas  carneae,  as 
in  functional  murmurs  which  disappear  when  the  ner- 
vous system  returns  to  a  state  of  quiet  health,  or  to 
organic  change  in  the  form  of  the  heart  or  its  muscular 
attachments,  or  to  damage  done  by  deposits  on  the 
mitral  valve  or  the  chordas  tendinese.  The  murmur  is 
always  loud  and  noisy,  and  has  infinite  variety.  It  may 
be  of  no  alarming  import,  or  it  may  be  an  indication  of 
serious  damage  done  to  the  mitral  valve.  It  may  be  a 
soft  blowing  sound,  diffused  all  over  the  chest,  and  yet 
seeming  to  follow  the  course  of  the  blood-stream  sent 
from  the  heart,  or  it  may  be  louder,  of  a  bellows  char- 
acter, heard  with  greatest  intensity  over  the  base  of  the 
heart,  and  extending  but  little  into  the  column  of  flow- 
ing blood,  and  then  it  tells  of  hypertrophied  ventricular 
walls.  And  if  a  murmur  is  heard  in  addition  to  this  at 
the  apex  beat,  loud  and  harsh,  of  varied  pitch,  rasping, 
sawing,  blubbering,  flapping,  it  is  a  sign  that  with  the 


15^  DISEASES   OF  THE   HEART  AND   LUNGS. 

hypertrophy  there  is  extensive  damage  done  to  the  mi- 
tral valve.  This  murmur  has  its  seat  over  the  base  of  the 
heart,  and  at  the  apex-beat,  and  may  run  round  under  the 
axilla  and  appear  at  the  lower  angle  of  the  scapula 
behind,  on  the  left  side,  or  it  may  pass  from  the  apex- 
beat  toward  the  sternum,  just  as  the  sound  may  be  sent 
into  the  rib  by  the  motion  of  the  heart  as  it  strikes  the 
chest-wall.  It  adds  something  to  the  character  of  the 
aortic  obstructive  murmur  and  to  the  mitral  regurgitant, 
as  heard  between  the  seventh  and  eighth  vertebrse  be- 
hind. It  attracts  the  attention  of  the  beginner,  for  it  is 
easily  heard,  and  it  frequently  misleads  the  practitioner 
as  to  the  gravity  of  the  disease.  It  has  been,  in  some 
of  its  varieties,  considered  a  diagnostic  sign  of  mitral 
regurgitation,  and  some  varieties  of  it  have  been  called 
by  eminent  auscultators  a  "presystolic  murmur,"  or  an 
"  auricular  systolic  murmur,"  or  a  ''  mitral  direct  mur- 
mur." 

I  think  it  was  Grisolle  who  first  described  what  he 
called  a  presystolic  murmur.  Dr.  Gairdner,  of  Edin- 
burgh, describes  the  same  murmur,  and  calls  it  an  auric- 
ular systolic  murmur ;  and  our  own  eminent  ausculta- 
tor.  Dr.  Flint,  calls  it  the  mitral  direct. 

If  we  allow  the  cause  to  be  as  is  described,  the  name 
auricular  systolic  would  be  most  appropriate. 

It  is  claimed  to  be  heard  just  before  the  ventricular 
systole  has  commenced,  and  to  be  caused  by  the  con- 
traction of  the  auricle  forcing  the  blood  into  the  ven- 
tricule  through  a  diseased  and  contracted  auriculo-ven- 
tricular  orifice,  sometimes  appearing  like  a  buttonhole 
slit.  The  argument  is,  the  murmur  is  heard,  and  the 
disease  exists,  therefore  the  forcible  passage  of  blood 
through  the  orifice  causes  the  murmur.  We  will  en- 
deavor to  prove  that  the  murmur  is  not  caused  by 
forcible  passage  of  blood   through  the  diseased  and 


CARDIAC   MURMURS.  1 59 

narrowed  orifice,  and  secondly  to  account  for  the  mur- 
mur in  a  more  satisfactory  manner. 

The  walls  of  the  auricle  are  thin  and  its  power  is 
but  feeble.  It  may  be  doubted  that  the  auricle  has 
sufficient  power  to  force  a  stream  of  blood  into  an 
empty  ventricle,  so  as  to  cause  a  murmur  that  would 
be  audible  at  the  apex  beat.  And  it  is  still  more  in- 
credible, for  it  is  impossible  that  such  a  murmur  could 
be  formed  when  the  ventricle  is  full  of  blood. 

When  we  recollect  that  the  murmur  of  regurgitation 
through  the  aortic  valve,  is  but  feeble,  and  scarcely 
heard,  notwithstanding  the  great  force  by  which  it  is 
made;  or  the  true  mitral-regurgitant  murmur,  which 
is  not  loud  and  is  easily  observed,  but  which  is  formed 
with  all  the  force  of  the  powerfully  contracting  ven- 
tricle ;  we  cannot  conceive  that  so  feeble  a  cause,  so 
far  removed  from  the  ear,  could  make  so  loud  and 
harsh  a  murmur.  Then,  too,  it  must  be  remembered 
that  the  auricle  and  its  appendix  are  rather  a  recep- 
tacle than  a  motive  power.  The  auricle  is  not  a  shut 
sack,  and  it  has  no  valve  to  prevent  regurgitation  to- 
wards the  lungs ;  and  that  a  bending  or  folding  upon 
itself  would  not  be  sufficient  to  prevent  the  blood  being 
sent  back  with  damaging  effect.  Again,  the  murmur 
as  heard  is  of  considerable  length  in  duration,  while  the 
time  of  the  auricular  contraction  is  exceedingly  short. 

Harvey,  as  well  as  other  observers,  describes  the 
motion  of  the  auricle  in  contraction  as  beginning  sud- 
denly ;  a  wave-like  motion  which  passes  immediately 
downward  into  the  ventricle,  instantly  closing  the  mi- 
tral valve  by  contraction  of  the  ventricle  and  sending 
the  blood  into  the  aorta.  The  murmur  heard  cannot 
be  formed  by  the  auricular  systole,  for  there  is  no 
agreement  in  time. 

And  again,  the  murmur  heard   is  entirely  different 


t6o  DISEASES  OF  THE  HEART  AND   LUNGS. 

from  that  of  blood  being-  rushed  through  an  aperture, 
which  would  be  like  the  sound  of  fluid  being  forced 
through  the  nozzle  of  a  syringe  into  water,  and  would 
necessarily  have  a  great  degree  of  uniformity  ;  while 
the  sound  actually  heard  is  infinitely  varied  in  quality, 
tone,  and  pitch. 

And  lastly,  in  disease  of  the  mitral  valve,  intermission 
of  the  ventricular  systole  is  a  frequent  occurrence,  but 
not  so  with  the  auricular ;  that  is  not  intermitted  ;  and 
yet  I  have  never  heard,  nor  heard  of,  an  auricular  sys- 
tolic murmur  during  a  ventricular  intermission.  I  have 
listened  carefully  to  a  heart  with  extensively  diseased 
mitral  valve,  where  the  ventricular  intermission  was  six- 
teen seconds  in  time,  and  during  that  intermission  there 
was  silence.  Are  not  these  facts  satisfactory  evidence 
that  this  murmur  is  not  caused  by  the  auricular  sys- 
tole ? 

How,  then,  is  this  murmur  formed  ?  If  we  refer  back 
to  the  argument  of  the  cause  of  the  first  sound,  it  will 
give  us  the  key.  These  murmurs  are  mostly  heard  when 
the  mitral  valve  is  much  diseased,  of  which  they  are  a 
sign.  The  thickening  and  irregularity  of  the  mitral 
valve,  with  the  irregularly  hypertrophied  ventricular 
walls  and  calumnse  carneae,  are  the  physical  causes  of 
the  murmur.  These  will  produce  in  contraction  irreg- 
ular tension  of  the  chordas  tendinae,  and  especially  of 
those  in  the  upper  part  of  the  ventricle.  Some  of  these 
cords  may  have  slight  tension  or  none  at  all  and  vi- 
brate slowly,  producing  a  blubbering  murmur ;  while 
others,  at  the  same  time,  may  be  under  great  tension 
and  give  a  harsh  rasping  murmur  of  high  pitch.  Some 
from  the  altered  form  of  the  heart  may  be  brought 
suddenly  into  tension  with  a  snap  as  described  by  Dr. 
Ormerod.  They  are  all  formed  at  the  commencement 
of  the  ventricular  systole,  as  is  proved  b}^  the  prepon- 


CARDIAC   MURMURS.  l6l 

derance  of  the  mitral-valve,  element  in  their  composi- 
tion, and  are  only  varieties  of  the  non-regurgitant  mur- 
mur, having  their  origin  in  the  vibrations  of  the  chordeae 
tendineas  reproduced  in  the  tense-mitral  valve,  and  with- 
inthe  time  of  the  first  sound  or  ventricular  systole.* 

The  murmurs  connected  with  the  right  side  of  the 
heart  are  few,  and  all  belong  to  the  tricuspid  valve.  As 
before  stated,  the  pulmonary  semilunar  valve  is  not  lia- 
ble to  disease. 

The  tricuspid  is  liable  to  the  same  damage  from  de- 
posits, etc.,  as  the  mitral,  but  much  less  frequently. 
Sometimes  in  deformity  of  the  chest  from  angular  cur- 
vature of  the  spine  the  heart  may  be  so  dislocated  that 
the  right  heart  might  be  brought  near  the  chest  wall, 
when  its  sounds  may  be  studied  in  the  same  manner  as 
we  ordinarily  study  those  of  the  left  heart. 

A  tricuspid  intraventricular  murmur  is  not  remark- 
ably infrequent,  but  is  much  less  frequent  than  the  mit- 
ral. It  is  heard,  ordinarily,  at  the  lower  part  of  the 
sternum,  or  by  the  left  side  of  it,  over  the  costal  car- 
tilages ;  or  it  may  be  heard  at  the  upper  part  of  the 
sternum,  running  out  under  the  left  clavicle.  It  has 
the  same  character  as  the  mitral  non-regurgitant ;  and 
though  more  distant  from  the  ear  and  less  sonorous, 
is  evidently  formed  in  the  same  way.  The  right  ven- 
tricle is  liable  to  hypertrophy  from  pulmonary  obstruc- 
tion, and  this  will  produce  the  murmur  described.  This 
valve  may  also  be  damaged  by  deposits,  etc.,  as  the 
mitral  is,  and  the  diagnosis  will  be  in  the  character  of 
the  murmur,  heard  over  the  cartilages  by  the  left  side 
of  the  xiphoid  cartilage.  I  know  of  no  certain  sign  of 
tricuspid  regurgitation.    The  right  auricle  has  its  natu- 


*Prof.  Donaldson  adopts  this  view  in  a  paper  entitled,  "Significance 
of  the  Praesystolic  Murmurs." — F.  Donaldson,  M.D,,  1874. 


1 62  DISEASES   OF  THE   HEART   AND   LUNGS. 

ral  bed  in  a  hollowing  out,  as  it  were,  of  the  right  lung  in 
its  middle  part,  and  should  there  be  a  stream  of  blood  re- 
gurgitated through  the  right  auriculo-ventricular  open- 
ing it  would  impinge  upon  the  side  of  the  auricle,  and 
the  murmur  would  be  lost  in  its  diffusion  in  the  lung, 
and  would  not  be  brought  to  the  chest  wall,  unless  by 
consolidated  lung.  I  have  never  heard  it,  and  do  not 
know  that  it  has  ever  been  verified. 

In  a  monograph  on  the  *'  right  side  of  the  heart,"  by 
Thomas  Mee  Daldy,  M.D.,  late  President  of  the  Hun- 
terian  Society,  London,  there  is  a  condition  pointed  out 
which  Dr.  Daldy  calls  "  a  distensible  right  auricle."  It 
is  not  accompanied  with  a  murmur,  but  it  causes  the 
heart's  sounds  to  be  heard  distinctly  to  the  right  of  the 
sternum  at  the  upper  part  and  out  under  the  clavicle, 
and  there  is  dulness  under  percussion  to  the  right  of 
the  sternum  in  the  region  of  the  auricle.  This  disten- 
sible condition  is  apt  to  be  overlooked  in  post-mortem 
examination,  for  the  auricle  is  not  apparently  diseased. 
But  the  fact  may  be  demonstrated  by  filling  -the  auricle 
with  water,  and  by  inspecting  its  bed  in  the  lung,  which 
will  be  found  larger  than  usual. 

Dr.  Daldy  says  this  condition  is  sometimes  inherited, 
and  is  connected  with  dyspepsia.  It  is  the  cause  of  cer- 
tain forms  of  asthma  or  apnoea,  and  of  frequent  conges- 
tive head-aches,  which  sometimes  end  in  insanity. 

I  think  I  have  verified  the  physical  conditions  de- 
scribed by  Dr.  Daldy  in  one  or  two  instances. 

In  the  foregoing  paper  I  have  endeavored  to  be  prac- 
tical, without  claiming  to  be  very  original,  and  to  give 
my  own  experience  as  corroborative  of  that  of  the  late 
Dr.  Cammann.* 

*  On  Cardiac  Mur?jturs.     By  the  late  Dr.  Cammann,  New  York  City. 
[The  following  brief  article,  which  has  never  before  been  published, 
although  read  before  the  New  York  Academy  of  Medicine,  was  found 


CARDIAC    MURMURS.  163 

among  Dr.  Cammann's  papers  subsequent  to  his  death.  It  is  of  impor- 
tance in  connection  with  Dr.  Leaming's  paper  on  the  same  subject, 
which  is  given  above. — Ed.  New  York  Medical  Journal.] 

AORTIC    OBSTRUCTIVE    SYSTOLIC. 

When  it  reaches  the  apex  it  is  with  diminished  intensity.  When  heard 
behind,  it  is  most  distinct  at  the  left  of  the  third  and  fourth  vertebrae, 
close  to  their  spines,  and  frequently  extends  downward  along  the  spine 
in  the  course  of  the  aorta,  but  with  diminished  intensity. 

Although  the  heart  extends  only  as  high  as  the  fifth  vertebra,  the  mur- 
mur is  heard  above  that  point,  because  here  the  aorta  approaches  the  sur- 
face. 

AORTIC    REGURGITANT    DIASTOLIC. 

Intensity  from  valve  to  right  of  apex,  may  or  may  not  increase  down- 
ward, depending  on  proximity  of  the  heart  to  the  parietes,  position  of 
the  lungs,  etc. ;  it  may  decrease  downward,  however,  from  emphysema, 
supine  recumbency,  etc. ;  it  may  perchance,  be  loudest  at  the  apex,  but 
depending  on  the  proximity  of  the  heart  to  the  parietes,  position  of  parts, 
condition  of  mitral  valve,  etc.  Generally  it  is  not  heard  behind,  but  it 
may  be,  toward  the  inner  side  of  the  lower  angle  of  the  scapula,  in  thin 
subjects  especially,  in  the  same  place  where  is  heard  the  mitral  non-re- 
gurgitant  murmur;  this  mitral  non-regurgitant  being  the  mitral  regurgi- 
tant of  Bellingham  and  others.  It  is  sometimes  conveyed  to  the  left  ax- 
illa.    The  patient  when  recumbent  may  sometimes  hear  it  himself. 

MITRAL    SYSTOLIC    REGURGITANT. 

To  indicate  regurgitation  the  murmur  must  be  heard  between  the  lower 
border  of  the  fifth  and  the  upper  border  of  the  eighth  vertebrae,  at  the 
left  of  the  spine,  provided  that  the  transmission  of  the  sound  be  not  in- 
terfered with  by  thickness  of  integuments  or  other  condition  of  parts. 
When  not  heard  in  this  place,  but  in  the  "  left  axilla  and  region  of  left 
scapula,"  regurgitation  is  not  indicated,  or,  in  other  words,  it  is  a  non-re- 
gurgitant murmur,  contrary  to  the  teaching  of  Bellingham  and  others. 
If  there  be  a  systolic  murmur  with  a  maxinium  of  intensity  between  the 
seventh  and  eighth  vertebrae  at  the  left  of  the  spine,  it  indicates  regurgi- 
tation. 

An  aneurismal  murmur,  however,  may  be  heard  within  the  said  limits, 
but  it  follows  the  aorta  downward,  gradually  decreasing  in  intensity  with- 
out the  abrupt  termination  of  the  regurgitant  murmur.  We  occasionally 
meet  with  mitral  regurgitant  murmur  posteriorly  yet  absent  anteriorly. 

The  following  complication  may  exist,  namely:  aortic  obstructive 
systolic,   with  aortic  regurgitant  diastolic  extending    to  the    apex,   with 


164  DISEASES   OF  THE  HEART  AND   LUNGS. 

mitral  regurgitant  behind  without  a  corresponding  murmur  in  front. 
All  of  these  murmurs  are  not  unfrequently  heard  to  the  right  of  the  apex, 
and  even  over  the  whole  chest. 

A  mitral  diastolic  murmur  we  have  not  heard.  If  it  be  ever  present, 
as  stated  by  distinguished  auscultators,  it  must  depend  upon  physical 
conditions  external  to  the  heart.  Pleuritic  effusions  or  the  like  in  certain 
positions,  by  pressing  suddenly  and  strongly  upon  the  left  auricle,  may 
possibly  force  the  blood  with  such  rapidity  through  an  obstructed  au- 
riculo-ventricular  orifice,  as  to  cause  an  abnormal  sound. 

Some  auscultators,  however,  deny  the  possibility  of  the  occurrence  of 
this  murmur  under  any  contingency  whatever. 

Addendum. — The  mitral-regurgitant  murmur  behind  may  disappear, 
from  such  a  change  in  the  structural  condition  of  the  diseased  valve,  or 
from  such  contraction  of  the  auriculo-ventricular  opening,  as  will  allow 
the  valve  to  close  during  the  systole  ;  there  being,  in  this  case,  actually 
an  increase  of  the  mechanical  obstruction. 


DISTURBED  ACTION   OF  THE   HEART.  1 65 


IX. 

Significance    of    Disturbed    Action    and    Func- 
tional Murmurs  of  the  Heart.* 

In  April,  1868,  I  had  the  honor  of  reading  a  paper 
on  ''  Cardiac  Murmurs"  before  the  New  York  County 
Medical  Society,  in  which  my  endeavor  was  to  sub- 
stantiate the  true  diagnostic  sign  of  mitral  regurgita- 
tion ;  and  also  the  significance  of  intra-ventricular  ojr 
mitral  non-regurgitant  murmurs,  as  were  held  by  my 
friend  the  late  Dr.  Cammann.  He  had  demonstrated, 
by  pathological  investigations,  that  the  signs  of  mitral 
regurgitation  as  generally  taught — murmurs  at  the 
apex  beat,  blowing,  sawing,  rasping,  etc. — were  unreli- 
able, but  that  the  true  and  invariable  sign  is  a  murmur 
of  an  entirely  different  character — a  soft  murmur,  a 
blood-friction  murmur,  such  as  would  naturally  be 
formed  by  forcing  fluids  through  an  aperture,  and 
which  is  heard  behind,  between  the  seventh  and  eight 
vertebrae  of  the  left  side,  close  to  their  spines.  With 
this  sign  alone  is  mitral  regurgitation  certainly  diag- 
nosticated. The  mechanism  of  the  first  sound  is 
evidently  the  key  to  a  correct  diagnosis  of  a  large  ma- 
jority of  heart-murmurs,  both  functional  and  organic. 
The  theories  of  the  cause  of  the  first  sound,  according 
to  Bellingham,  ''  may,' for  convenience'  sake,  be  consid- 
ered, as  the  cause  is  supposed  to  be  extrinsic  or  in- 
trinsic to  the  heart.  Thus,  under  the  first,  it  has  been 
attributed  to  the  impulse  of  the  apex  against  the 
parietes  of  the  chest ;   under  the  second  head,  it  has 

*  Read  March  18,  1875,  befora  the  N.Y.  Academy  of  Medicine, 


1 66  DISEASES   OF  THE   HEART   AND    LUNGS. 

been  attributed  to  muscular  contraction  — ■  in  other 
words,  to  the  successive  shortening  of  the  muscular 
fibres  of  the  parietes  of  the  ventricles.  This  is  the 
oldest  theory ;  it  was  adopted  by  Harvey,  Haller, 
Senac,  Bichat,  and  Corvisart.  2.  To  the  sudden  ten- 
sion of  the  auriculo-ventricular  valves.  3.  To  the  fric- 
tion of  the  blood  against  the  parietes  of  the  interior  of 
the  ventricles,  or  of  the  orifices  of  the  large  arteries. 
4.  To  the  collision  of  the  opposite  internal  surfaces  of 
the  ventricles  at  the  conclusion  of  the  systole.  5.  To 
the  sudden  elevation  of  the  sigmoid  and  semilunar 
valves,  caused  by  the  wave  of  blood  transmitted  by  the 
ventricles.  6.  To  the  concussion  of  the  blood  trans- 
mitted by  the  systole  of  the  left  ventricle,  with  that 
contained  in  the  aorta ;  and,  lastly,  to  two  or  more  of 
the  the  foregoing  causes  combined." 

I  chose  to  consider  as  worthy  of  attention  only  three 
of  the  theories  in  vogue:  i.  That  of  friction  of  the 
blood  in  its  motion,  within  the  ventricle,  and  its  pas- 
sage into  the  aorta.  2.  That  of  the  muscular  contrac- 
tion of  the  heart  itself  producing  sound-vibrations,  as 
shown  by  Dr.  Wollaston,  in  1810;  and,  3.  That  of  the 
vibrations  of  the  mitral  valve,  caused  by  its  closure 
and  tension,  and  the  forcing  and  rushing  blood  ;  and 
lastly,  that  some,  recognizing  the  possibihty  of  each  of 
these  three  causes  mentioned  producing  sound,  have 
believed  that,  as  the  first  sound  is  evidently  composite, 
it  is  the  result  of  all  three.  This  was  the  theory  held 
by  Dr.  Cammann. 

As  none  of  these  theories  seemed  to  me  to  agree 
with  all  the  conditions,  and  especially  with  acoustical 
conditions,  I  was  impressed  with  the  truth  that  they 
did  not  give  satisfactory  evidence  of  the  cause  of  the 
first  sound,  and  that  we  must  direct  attention  to  the 
heart  itself  for  new  proof  on  this  vexed  question.     We 


DISTURBED  ACTION   OF  THE   HEART.  167 

find  a  pecular  musical-instrument  arrangement  within 
the  heart,  of  a  drum-like  expansion  of  fibrinous  tissue, 
to  which  are  attached  fine,  tendinous  cords,  joining 
each  part  of  the  valve  to  the  wall  of  the  heart,  through 
the  intervention  of  bundles  of  muscular  fibres — columnae 
carnese,  or  musculi  papillares.  It  seems  incredible  that 
such  admirable  conditions  for  producing  sound-vibra- 
tions could  have  so  long  been  overlooked  by  the  many 
able  observers,  as  the  most  probable  cause  of  the  first 
sound. 

That  the  first  sound  is  caused  by  vibrations  of  the 
chordae  tendinse,  connected  with  the  mitral  valve  in  the 
left  heart,  and  with  the  tricuspid  in  the  right,  set  in 
motion  by  the  swift  current  of  forced  blood,  is  a  rea- 
sonable postulate.  If  this  doctrine  can  be  proved  by 
pathological  evidence  of  undoubted  character,  it  sim- 
plifies our  investigation.  If  plastic  lymph  be  exuded 
upon  the  surface  of  the  valve,  or  upon  its  edges,  gluing 
them  together,  and  if  at  the  same  time  the  chordae  ten- 
dinese  are  shortened  and  thickened  by  exuded  plastic 
lymph,  or  glued  down  upon  the  valve  so  as  to  prevent 
vibration,  then,  if  the  first  sound  is  altered,  and  all  mur- 
murs are  abolished,  it  must  be  admitted  that  the  proof 
is  sufficient.  The  following  cases  are  offered  as  sup- 
plying such  convincing  evidence : 

Case  I.  July  6^  1859. — John  Martin:  Is  a  native  of 
England  ;  educated  at  Eton  ;  forty-two  years  old  ;  dur- 
ing the  last  ten  years  has  been  dissipated,  and  has  had 
syphilis ;  had  rheumatism  eight  years  ago,  which  kept 
him  in  bed  two  weeks ;  and  has  since  had  frequent 
rheumatic  pains  ;  with  these  exceptions,  has  been  well 
until  about  two  years  ago,  when  his  appetite  failed,  and 
he  vomited  mornings  after  taking  beer  ;  and  his  weight 
declined  from  one  hundred  and  ninety  to  one  hundred 
and  forty-four  pounds.     Two  days  ago,  while   at   his 


l68  DISEASES   OF  THE  HEART  AND   LUNGS. 

business,  there  was  momentar}^  loss  of  consciousness 
without  falling,  and  similar  attacks  occurred  frequently 
until  last  night,  when  they  prevented  sleep. 

Examination. —  The  pulse  grew  gradually  weaker, 
until  it  could  no  more  be  felt,  and  at  the  same  time  the 
respiration  would  be  suspended.  The  interval  was  so 
long,  that  I  looked  in  his  face  to  see  if  he  was  not  dead  ; 
when,  with  a  full  inspiration,  and  a  strong  throb  of  the 
pulse,  both  would  commence  again  and  continue  about 
fifteen  pulse-beats,  then  cease,  and  begin  again  as  be- 
fore. In  addition  to  this  were  the  attacks  of  ''petite 
mal" — his  face  would  flush  slightl}^,  and  his  eyes  stare 
as  if  he  saw  a  strange  object — this  would  scarcely  in- 
terrupt his  conversation,  when  he  would  go  on  again 
as  if  nothing  had  happened.  These  epileptiform  seiz- 
ures came  during  the  intermissions  of  the  pulse  and 
breathing,  as  well  as  at  other  times. 

Auscultation  of  the  chest  discovered  no  fault  in  res- 
piratory murmurs.  There  a  was  slight  systolic  cardiac 
murmur,  aortic-obstructive.  After  an  intermission  of 
the  heart-beat,  which  agreed  in  length  with  the .  inter- 
mission of  the  pulse,  it  would  begin  again  with  a  for- 
cible impulse,  which  gradually  decreased  in  strength 
until  it  ceased  to  be  felt  or  heard,  after  which  one  con- 
traction of  the  heart  could  be  heard  like  a  whisper, 
but  without  vocal  sound  and  without  impulse-beat. 
The  sound  of  this  contraction  was  peculiar;  it  was 
as  if  no  blood  was  being  forced  into  the  aorta  by 
ventricular  contraction.  By  careful  counting,  repeated 
a  number  of  times,  the  exact  time  of  the  heart's  rest 
was  found  to  be  sixteen  seconds.  The  heart  seemed  to 
beat  in  a  wild  and  peculiar  manner,  as  if  outside  of  the 
pericardium,  and  the  point  of  impulse  varied  an  inch 
or  an  inch  and  a  half. 


DISTURBED   ACTION   OF  THE   HEART.  1 69 

The  next  day  Dr.  T.  M.  Halstead  was  called  as 
counsel,  the  conditions  remained  unchanged. 

%th. — Was  called  at  6  a.  m.  to  see  the  patient,  who 
was  supposed  to  be  dying.  I  was  informed  that  an  in- 
termission of  extraordinary  length  had  occurred.  Res- 
piration and  pulsation  had  ceased,  the  hands  fell  by  his 
side,  his  chin  dropped,  his  head  inclined  to  one  side, 
and  his  face  become  livid.  His  sister,  who  sat  by  him, 
believing  him  to  be  dying,  called  his  wife  ;  her  outcries 
awakened  him,  and  after  short  time  he  recovered,  and 
was  as  he  had  been  before.  When  I  arrived  his  pulse 
was  25  in  the  minute,  as  it  had  been  from  the  first,  and 
his  state  remained  unchanged  in  both  signs  and  symp- 
tons. 

Friday,  loth,  7  P.  M. — Dr.  Alonzo  Clark  was  added  to 
the  consultation.  Dr.  Clark  found  the  time  of  inter- 
mission of  the  pulse  to  be  thirteen  seconds  ;  the  seizures 
are  a  little  more  violent,  and  he  is  nervous.  Physical 
signs  the  same  as  before. 

II />^. — Patient  has  slept  during  the  night.  The  epilep- 
tiform seizures  ceased  at  midnight,  and  the  pulse  has 
become  regular  without  intermissions — 52  in  a  minute. 
After  this  the  patient  steadily  improved,  and  one  month 
afterward  he  walked  to  Dr.  Cammann's  office  in  Fourth 
Avenue.  Dr.  Cammann  diagnosticated  systolic  ob- 
structive murmur,  with  hypertrophy  of  the  heart,  but 
believed  the  irregular  action  and  peculiar  symptoms 
were  owing  to  functional  derangement  from  indiges- 
tion. .  He  became  well  enough  to  attend  to  business 
until  October,  1861,  when  he  was  again  taken  ill.  There 
were  then  anasarca,  dyspnoea,  and  laboring  heart  with 
obscure  physical  signs.  He  gradually  failed,  and  died 
on  November  26,  1861. 

Post-mortem  on  27th,  assisted  by  Dr.  Loomis.  Com- 
plete adhesion  of  the  pericardium  to  the  heart.     There 


I/O  DISEASES   OF   THE   HEART   AND   LUNGS. 

was  no  free  space,  but  in  some  parts  the  adhesions  were 
stronger  and  apparently  older  than  in  others.  The 
heart  was  largely  hypertrophied,  but  was  not  weighed. 
The  curtains  of  the  aortic  valve  were  thickened  and 
shortened  to  incompetency,  not  holding  water.  The 
edges  of  the  mitral  valve  were  glued  together,  extend- 
ing into  the  ventricle  like  a  funnel :  complete  stenosis. 
The  opening  very  small,  the  valve  and  chordae  were 
thickened  and  covered  with  plastic  lymph,  white  and 
glistening. 

Case  II.  {Substance  of  Re7narks  made  by  J  AMES  R. 
Teaming,  M.D.,  before  the  Pathological  Society  on  the  Pre- 
sentation of  a  Specimen  for  a  Candidate  for  Admission^ — 

Mrs.  B ,  twenty-three  years  of  age,  native  of  New 

York,  widow,  called  Dr.  S ,  in  April,  1869,  for  ad- 
vice as  to  cardiac  trouble  and  swelled  feet.  The  doc- 
tor found,  on  examination,  a  systolic  murmur  over  the 
base  of  the  heart,  more  distinct  over  the  aortic  valves, 
gradually  disappearing  to  the  right  in  the  course  of  the 
aorta  ;  there  was  also  a  diastolic  murmur. 

Diagnosis. — Aortic  obstruction  and  aortic  regurgita- 
tion, with  hypertrophy  of  left  ventricle.  There  were 
also  casts  in  the  urine  and  albumen.  She  became  drop- 
sical, her  condition  gradually  grew  worse,  and  she  died 
in  September  last. 

I  saw  the  case  with  Dr.  S ,  in  May,  and  found  no 

different  conditions  than  those  already  discovered. 
There  was  no  mitral  'inurmur  of  any  kind.  The  speci- 
mens here  presented  show  Bright's  small  kidney  of 
advanced  disease.  The  heart  is  hypertrophied  mostly 
in  the  left  ventricle  ;  the  aortic  valve  is  thickened  at  the 
base  of  the  curtains ;  shortened  to  incompetency — so 
far,  agreeing  with  the  diagnosis.  But  the  mitral  valve 
presents  the  most  notable  feature.  There  was  no  sign  of 
disease  of  this  yalve  during  life,  and  yet  it  is  damaged 


DISTURBED   ACTION   OF   THE  HEART.  171 

in  a  very  peculiar  manner.  It  is  thickened  by  lymph- 
deposit  ;  its  color  white,  opaque ;  the  edges  of  the 
curtain  are  adherent,  and  the  orifice  is  narrowed  down 
till  it  will  barely  admit  the  top  of  the  index-finger ;  and 
the  whole  valve  extends  down  into  the  cavity  of  the 
ventricle  like  a  funnel.  The  chordse  tendinas  were 
shortened  and  thickened  by  lymph-deposits,  and  the 
musculi  papillares  were  thickened  and  lengthened. 
But  every  thing  was  symmetrical,  viz.,  the  funnel-like 
condition  of  the  valve,  the  hypertrophy  of  the  cardiac 
walls,  of  the  musculi  papillares,  and  of  the  columnae 
carneae.  With  all  of  the  conditions  for  producing  a  so- 
called  mitral  direct  murmtir^  there  were  neither  mitral 
murmur  nor  first  sound. 

Case  III.  {Copied  froin  Reports  of  the  Pathological 
Society,  published  in  the  Medical  Record  in  187 1.) — Dr. 
Loomis  presented  a  heart,  with  the  following  history, 
from  Dr.  Milliken,  house-physician  of  Bellevue :  "  Henry 
Clemens,  admitted  April  11,  1871,  aged  thirty-two; 
single  ;  cabinet-maker  by  occupation  ;  nativity,  Switzer- 
land. Patient  gives  hereditary  history  of  pulmonary 
phthisis.  Had  an  attack  of  articular  rheumatism  when 
seventeen  years  of  age,  from  which  he  made  a  good 
recovery.  States  that  neither  at  that  time,  nor  since, 
has  he  experienced  any  precordial  pain,  but  has  noticed 
that  after  indulging  in  tobacco  (for  he  has  been  an 
inveterate  smoker)  he  would  suffer  from  palpitation  of 
the  heart.  He  had  had  a  cough,  dating  some  time 
back,  with  some  expectoration  of  a  pearly  white  ma- 
terial, which  he  says  he  coughs  up  at  night,  at  which 
time  his  cough  distresses  him  most.  About  two  weeks 
ago,  for  the  first  time,  he  noticed  that  the  sputa  were 
streaked  with  blood.  His  cough  remained  about  the 
same  in  character  until  one  week  ago,  when  he  expe- 
rienced a  severe   paroxysm    of    coughing,  which  was 


172  DISEASES   OF  THE  HEART  AND   LUNGS. 

instantly  followed  by  haemoptysis,  which  continued  for 
two  or  three  days.  Since  the  occurrence  of  haemopty- 
sis, he  has  had  night-sweats,  loss  of  appetite,  deprecia- 
tion of  strength,  and  experienced  a  feeling  of  general 
malaise,  and  inaptitude  for  any  kind  of  work ;  he  com- 
plains also  of  insomnia  and  restlessness.  His  pulse  is 
about  80,  regular,  but  quite  feeble ;  respiration  some- 
what hurried  and  easily  performed.  Heart:  action 
regular,  but  quite  feeble ;  apex-beat  on  a  level  with 
nipple  in  fifth  interspace.  Heart-sounds  feeble ;  after 
repeated  examinations,  no  murmurs  could  be  detected'' 

The  record  proceeds  to  say  that,  while  the  patient 
was  at  dinner,  he  became  suddenly  unconscious  and 
fell  from  his  chair,  and  symptoms  of  paralysis  continued 
until  the  i8th,  when  he  died.  Post-mortem  showed  em- 
bolism of  middle  cerebral  artery  of  left  side,  with  soft- 
ening of  brain-tissue.  Heart,  fourteen  ounces.  Both 
right  and  left  cavities  contain  large  clot  of  blood ;  sub- 
stance of  heart  relaxed ;  stenosis  of  mitral  orifice  only 
admits  little  finger ;  some  shortening  of  chordas  tendi- 
neae.  The  stenosis  is  due  particularly  to  the  thicken- 
ing, shortening,  and  adhesion,  of  the  chordas  tendineae 
of  the  valve.  The  anterior  portion  of  valve  forms  a 
bony  mass,  occluding  that  portion  of  the  orifice.  On 
the  auricular  aspect,  the  surface  of  the  valve  is  ulcer- 
ated, the  bony  matter  laid  bare,  and  soft,  reddish  vege- 
tations on  the  free  border  of  the  valve  and  upon  the 
ulcerated  surface.  Puhuonary  and  tricuspid  valves 
normal;  little  thickening  at  base  of  aorta." 

Dr.  Loomis  remarked,  ''  The  case  is  of  special  inter- 
est, because  with  this  marked  stenosis  no  murmurs 
existed;"  and  Dr.  Flint  remarked  that  "the  absence  of 
murmurs  might  be  accounted  for — i.  On  account  of 
rigidity  of  the  valve  not  allowing  a  vibration ;  and,  2. 
The  smoothness  of  the  ventricular  surface  of  the  valve," 


» 


DISTURBED   ACTION  OF  THE   HEART.  1 73 

The  first  case  is  full  of  instruction  in  its  facts  as  re- 
gards functional  disturbances  of  the  heart  and  proof  as 
to  the  mechanism  of  the  first  sound.  The  long  period 
of  rest,  sixteen  seconds,  is  worthy  of  our  earnest  atten- 
tion. Observers  who  have  watched  the  action  of  the 
heart  in  ectopia  in  an  infant,  as  Cruveilhier,  Bryan, 
and  others,  as  well  as  when  the  heart  has  been  exposed 
in  experiments  upon  animals,  tell  us  that  the  contrac- 
tions of  the  auricles  continue  regularly,  although  the 
ventricles  may  be  in  a  state  of  rest.  And  in  this  case 
no  doubt  they  did  so,  notwithstanding  that  there  was 
no  first  sound,  no  impulse-beat,  and  consequently  no 
contraction  of  the  ventricles.  The  importance  of  this 
fact  cannot  be  over-estimated,  because  it  invalidates 
much  of  the  theory  in  vogue  in  regard  to  the  causation 
of  murmurs.  It  proves  that  the  auricular  systole  may 
take  place  regularly,  even  when  the  auriculo-ventricu- 
lar  opening  is  very  much  contracted  in  stenosis  of  the 
mitral  valve,  without  producing  sound.  Carefully  lis- 
tening under  favorable  circumstances  after  the  last 
impulse-beat  and  first  sound,  one  contraction,  presum- 
ably that  of  the  ventricle,  could  be  heard,  without  any 
vocal  element  of  first  sound,  and  was  then  followed  by 
the  long  interval  of  silence,  in  which  no  contraction  or 
sound  of  any  kind  could  be  heard. 

The  second  case  is  a  demonstration  of  the  cause  and 
mechanism  of  the  first  sound.  There  was  no  mitral  mur- 
mur. With  stenosis  of  the  mitral  valve,  if  the  chordae 
tendineae  had  not  been  rendered  incapable  of  sound- 
vibrations,  by  being  plastered  over  with  fibrinous  de- 
posit, there  would  have  been  a  murmur,  such  as  is 
usually  heard  in  stenosis  where  the  chord2e  are  free 
and  uncovered.  The  first  sound,  and  all  murmurs  con- 
nected with  it,  disappearing  when  the  mitral  valve  and 
chordae  tendineae  are   rendered    incapable  of    sound- 


174  DISEASES   OF  THE  HEART  AND   LUNGS. 

vibrations,  is  as  convincing  proof  of  their  cause  as  is 
the  experiment  of  hooking  up  a  curtain  of  the  aortic 
valve  proof  as  to  the  cause  of  the  second  sound. 

The  second  and  third  cases  are  confirmatory  proof, 
by  different  observers,  that  the  cause  and  mechanism 
of  the  first  sound,  and  the  murmurs  connected  with  it, 
depend  upon  the  state  and  condition  of  the  mitral  valve 
and  its  chordae  tendineae.  In  the  second  case  there 
was  no  ph37sical  sign  of  disease  of  this  valve  during 
life,  and  yet  it  was  found  after  death  to  be  damaged  in 
a  very  peculiar  manner — thickened  by  lymph-deposits, 
opaque,  its  color  white,  the  edges  of  the  curtains  adhe- 
rent, the  orifice  narrowed  down,  barely  admitting  the 
tip  of  the  index  finger,  and  the  whole  valve  extending 
down  into  the  cavity  of  the  ventricle  fixed  and  like  a 
funnel.  The  chordse  tendineae  were  shortened  and 
thickened,  some  of  them  glued  to  the  valve,  and  the 
musculi  papillares  thickened  and  lengthened,  as  the 
specimen  which  I  now  present  to  you  demonstrates. 
This  case,  during  several  months,  was  under  the  obser- 
vation of  the  late  Dr.  Sprague,  a  careful  and  competent 
auscultator. 

The  third  case,  which  is  reported  in  the  Transactions 
of  the  New  York  Pathological  Society,  is  also  confirma- 
tory proof:  "  In  the  morbid  specimen  there  was 
stenosis  of  mitral  orifice— only  admits  little  finger — 
some  shortening  of  chordae  tendinese.  The  stenosis  is 
due  particularly  to  the  thickening,  shortening,  and  ad- 
hesion of  the  chordae  tendineae  of  the  valve."  During 
life,  heart-sounds  feeble  ;  after  repeated  examinations 
no  murmurs  could  be  detected.  Could  the  proof  be 
more  conclusive? 

The  following  experiments  by  Dr.  Halford,  quoted 
in  the  British  and  Foreign  Medico-Chirnrgical  Review, 
April,  i860,  is  singular  proof  of  the  physiological  cause 


DISTURBED   ACTION   OF  THE    HEART.  1 75 

of  the  first  sound^:  ''  My  proceedings  were  as  follows : 
large  dogs  were  obtained,  and  as  in  my  preceding  ex- 
periments (the  animals  being  under  the  influence  of 
chloroform),  the  heart  was  exposed  and  the  circulation 
kept  up  by  artificial  respiration.  A  stethoscope  being 
applied  to  the  organ,  the  sounds  were  distinctly  heard. 
The  superior  and  inferior  venae  cavas  were  now  com- 
pressed with  bull-dog  forceps,  and  the  pulmonary  veins 
by  the  finger  and  thumb  ;  the  heart  continuing  its 
action,  a  stethoscope  was  again  applied,  and  neither 
first  nor  second  sound  was  heard.  After  a  short  space 
of  time  the  veins  were  allowed  to  pour  their  contents 
into  both  sides  of  the  heart,  and  both  sounds  were  in- 
stantly reproduced.  The  veins  being  again  com- 
pressed all  sound  was  extinguished,  nowithstanding  that 
the  heart  contracted  vigorously.  Blood  was  let  in, 
and  both  sounds  were  restored.  I  have  thus  frequently 
interrogated  the  same  heart  for  upward  of  an  hour, 
and  always  with  the  like  result." 

The  reviewer  remarks :  "  There  is  an  interesting  cir- 
cumstance which  took  place  at  one  of  Dr.  Halford's 
experiments,  which  appears  to  us  of  great  importance. 
It  shows  that  when  only  a  small  quantity  of  blood  finds 
its  way  into  the  ventricles,  the  first  sound  is  still  pro- 
duced. The  cavas  and  pulmonary  veins  having  been 
compressed,  Mr.  Lane,  at  whose  request  the  experi- 
ment was  performed,  listened  to  the  heart  during  its 
contraction,  and  said  he  heard  the  first  sound  indis- 
tinctly, not  so  clearly  as  before  the  compression.  On 
examination  it  was  found  that  the  vena  azygos  entered 
the  right  auricle  by  an  independent  opening,  and  was 
not  secured :  the  vessel  was  compressed  with  the 
others,  the  heart  contracted,  no  sound  was  heard." 

This  experiment  proves  that  the  contractions  of  mus- 
cle of  the  heart  give  out  no  sound  which  may  be  an 


176  DISEASES   OF  THE   HEART   AND   LUNGS. 

element  of  the  first  sound ;  for  without  blood  moving 
through  the  heart  it  was  silent.  The  remaining  ele- 
ments, friction  of  the  blood  against  the  heart-wall  and 
through  the  aortic  orifice,  and  vibrations  of  the  chordae 
tendineae  and  mitral  valve,  must  give  answer  to  the 
question.  When  there  was  no  blood  forced  there  was 
no  sound ;  and  we  have  just  shown,  by  pathological 
specimen,  that  when  the  chordae  tendinese  were  ren- 
dered incapable  of  vibration,  there  was  also  neither 
sound  nor  murmurs.  Consequently,  the  first  sound 
and  murmurs  must  be  the  result  of  chord  and  valve 
vibrations  set  in  motion  by  the  rushing  blood.  The 
blood  is  the  bow  applied  to  the  strings  to  give  vibrat- 
ing sounds ;  and  murmurs  are  sounds  of  individual 
chord-vibrations  not  in  unison. 

One  of  the  points  I  endeavored  to  establish  in  1868 
was  that  the  presystolic  murmur,  called  also  the  auri- 
cular-systolic and  the  mitral  direct,  is  one  of  the  intra- 
ventricular murmurs,  caused  by  vibrations  of  chordae 
tendinese  subjected  to  irregular  tension,  and  not  by 
blood  bing  forced  through  the  contracted  opening  of 
the  mitral  valve  in  stenosis.  Although  frequently  con- 
nected with  that  pathological  condition,  it  is  yet  oftener 
an  accompaniment  of  change  of  the  mitral  valve  without 
stenosis.  My  argument  was,  as  Dr.  Cammann  first  con- 
tended, that  the  auricle  was  too  feeble  a  power  to  force 
blood  through  the  contracted  opening  of  the  diseased 
valve,  so  as  to  cause  sound  which  may  be  heard 
through  the  chest-wall,  even  if  empty,  much  less  so 
when  the  ventricle  is  filled  with  blood ;  and,  lastly,  I 
maintained  that  the  murmur  does  not  agree  in  length 
with  the  time  of  contraction  of  the  auricle.  According 
to  the  best  authorities,  the  contraction  of  the  auricle  is 
instantaneous,  while  the  murmur  is    of  considerable 


DISTURBED   ACTION   OF   THE   HEART.  1 77 

length.*  If  contraction  of  the  auricle  could  cause  the 
murmur,  the  two  ought  to  agree  in  time.  According 
to  Bellingham,  "  the  systole  of  the  auricle  is  a  quick, 
short,  sudden  motion."  Lower  says,  ''  Its  rapidity 
equals  the  explosion  of  gun-powder,  and  immediately 
precedes  the  ventricular  systole,  the  one  motion  ap- 
pearing to  be  propagated  by  the  other." 

Marey  assigned  to  it  two  tenths  of  the  time  of  the 
heart-beat,  which  is  probably  ten  times  longer  than  the 
reality,  and  much  less  than  the  time  of  the  so-called 
presystolic  murmur.  This  murmur,  too,  has  none  of 
the  qualities  of  sound  which  should  be  produced  by 
blood  forced  through  a  narrowed  opening  in  the  valve. 
But  all  argument  becomes  unnecessary  in  presence  of 
the  foregoing  pathological  facts  and  clinical  history. 
Dr.  Frank  Donaldson,  Professor  of  Physiology  and 
Hygiene,  and  Clinical  Professor  of  Diseases  of  the 
Chest  and  Throat,  University  of  Maryland,  in  a  paper 
read  before  the  Medical  and  Chirurgical  Faculty  of 
Maryland,  annual  session,  April,  1874,  on  "  Significance 
of  the  Presystolic  Murmur,"  relates  the  following 
cases,  with  remarks: 

"Some  years  ago  (in  1867)  a  case  came  under  my 
observation,  which  made  me  question  the  explanation 
which  I  had  adopted  on  the  authority  of  Earth,  Roger, 
Walshe,  and  Flint,  of  the  sound  which  was  described 
first  by  by  Fauvel,  in  1843,  ^^^  then  by  Grisolle,  as  the 
presystolic  murmur,  afterward  by  Dr.  Gairdner,  of 
Edinburgh,  as  the  auricular-systolic  murmur,  and  by 
Dr.  Austin  Flint  as  the  mitral  direct  murmur. 

''  These  authorities  claimed  that  this  sound  was  heard 
just  preceding  the  ventricular  contraction,  and  was 
caused  by  the  systole  of  the  auricle  forcing  the  blood 


*  Harvey,  Lower,  Bellingham. 


178  DISEASES   OF  THE   HEART  AND   LUNGS. 

into  the  ventricle,  through  a  diseased  and  contracted 
auriculo-ventricular  orifice. 

"  The  case  was  a  man  sixty -four  years  of  age,  of 
grossly  intemperate  habits,  who  came  to  the  Balti- 
more Infirmary  with  symptoms  of  advanced  heartr 
disease — great  dyspnoea,  a  small,  contracted  pulse, 
heart  much  hypertrophied,  with  a  murmur  of  a  rasping 
character,  heard  loudest  between  the  second  and  third 
ribs  at  the  base,  not  extending  up  the  carotids,  but 
down  toward  the  base,  and  completely  obliterating  the 
second  sound  of  the  heart.  The  murmur  was  audible 
after  the  apex-beat  and  the  systole  of  the  ventricle,  and 
was  followed  by  the  pause  of  the  heart.  The  first 
sound  of  the  heart  was  normal.  The  diagnosis  seemed 
clear  and  unmistakable,  and  was  recorded  as  insuffi- 
ciency of  the  aortic  orifice,  by  means  of  which  the  arte- 
rial blood  was  forced  back  into  the  left  ventricle. 

"Tho  J>ost  mortem  showed  atheromatous  degenera- 
tion in  the  aorta  above  the  semilunar  valves  extending 
to  the  sacs  of  Valsalva,  and  causing  adhesion  of  one  of 
the  semilunar  pouches  of  the  aortic  orifice  to  the  wall, 
so  bending  it  down  that  that  portion  of  the  orifice  was 
unprotected.  The  second  sound  could  not  be  produced, 
and  the  insufficiency  of  the  valve  was  evident. 

'^  Thus  far  the  diagnosis  was  correct,  but  on  examin- 
ing the  mitral  orifice  we  found,  to  our  surprise,  that  it 
was  reduced  by  thickening  at  its  base  to  about  the  size 
of  one  quarter  of  an  inch  in  diameter.  Yet,  during  life, 
there  was  no  abnormal  sound  preceding  or  during  the 
ventricular  systole.  With  such  a  contraction  of  the 
left  auriculo  ventricular  orifice,  ought  we  not  to  have 
had  a  decided  presystolic  murmur  ?  The  whole  heart, 
auricle  and  ventricle,  was  enlarged  and  increased  in 
force,  and  yet  there  was  no  murmur  produced  from  the 
passage  of  the  blood  through  an  orifice  so  reduced  in 


DISTURBED  ACTION   OF  THE  HEART.  179 

size  !  I  could  not  help  questioning  the  received  opin- 
ion as  to  the  significance  of  the  so-called  mitral  murmur. 
As  it  is  a  physical  sound,  heard  at  a  particular  period 
of  the  heart's  action,  the  physical  cause  which  was  said 
to  produce  it  being  present,  it  ought  to  have  been 
heard,  but  it  was  not. 

"  Hope,  as  far  back  as  1842,  reports  a  case  where  the 
mitral  orifice  was  so  contracted  that  it  would  only  ad- 
mit the  little  finger,  yet  there  was  no  murmur  during 
life,  preceding  the  first  sound.  In  his  report  he  adds: 
'  I  have  frequently  known  a  contraction  of  the  mitral 
orifice  to  the  size  of  only  two  or  three  lines,  to  occasion 
little  or  no  murmur.'  Dr.  Stokes,  in  his  work  on  *  Dis- 
eases of  Heart  and  Aorta,'  relates  two  cases  of  extreme 
contraction  of  the  mitral  orifice  found  after  death,  but 
where,  during  life,  there  had  been  no  murmur  audible 
even  to  his  practised  ear. 

"  Dr.  Waters.  His  first  case  was  where  he  heard  a 
loud  systolic  as  well  as  a  presystoHc  murmur.  At  the 
autopsy  there  were  found  insufficiency  and  slight  con- 
traction of  the  mitral  orifice.  In  the  second  case  there 
was  no  presystolic  murmur  whatever,  although  the 
autopsy  showed  a  constricted  mitral  orifice  only  admit- 
ting the  tip  of  the  index-finger.  Next  follow  the  details 
of  four  cases  of  extreme  contraction  of  the  mitral  ori- 
fice, where,  during  life,  there  was  no  presystolic  mur- 
mur audible.  He  candidly  adds  :  '  I  have  given  you 
instances  sufficient  to  prove  that  great  constriction 
of  the  mitral  orifice  may  exist  without  there  being  any 
murmur  produced  by  the  passage  of  the  blood  from 
the  auricle  into  the  ventricle,  and  therefore  that  you 
must  not  look  for  a  mitral-diastolic  or  presystolic 
as  a  constant  sign  of  obstructive  mitral  disease.  My 
belief  is  that  this  murmur  is  far  more  frequently 
absent  than  present,  even  when  there  is  great  great  ob- 


l8o  DISEASES   OF  THE   HEART  AND   LUNGS. 

struction  at  the  mitral  orifice/  Dr.  Waters  accounts 
for  the  presence  or  absence  of  this  murmur,  as  depend- 
ing on  the  greater  or  less  vigor  with  which  the  auricle 
contracts." 

Dr.  Donaldson  sums  up  his  relation  ol  cases  and  re- , 
marks  :  "  Thus  we  have  eleven  cases  of  the  lesion  with- 
out the  murmur,  and  three  cases  of  murmur  without 
the  lesion"  (quoting  the  latter  from  Dr.  Flint). 

The  diagnostic  sign  of  mitral  regurgitation,  which  has 
been  and  is  still  taught,  is  a  harsh,  blowing,  sawing,  or 
filing  murmur,  heard  during  the  systole  at  the  apex-beat. 
Upon  the  accepted  authority  of  this  murmur,  which  is 
so  often  met  with,  the  great  frequency  of  mitral  insuffi- 
ciency has  come  to  be  considered  as  incontrovertibly 
established. 

The  cases  we  have  already  related  are  proof  that 
these  murmurs  are  not  heard  when  the  chordae  tendi- 
nese  and  valve  are  rendered  unfit  for  sound-vibrations. 
J.  S.  Bristow,  M.  D.,  London,  F.  R.  C.  P.,  Physician  to 
St.  Thomas's  Hospital,  in  an  article  on  "  Mitral  Regur- 
gitation, arising  independently  of  Organic  Disease  of 
the  Mitral  Valve,"  in  the  July  number  of  the  British  and 
Foreign  Medico-Chirurgical Review  of  1861,  gives  six  cases, 
with  introductory  remarks.  With  your  permission  I 
will  read  some  of  his  arguments  and  quote  points  in 
the  cases,  for  the  purpose  of  showing  that  instead  of 
proving  that  regurgitation  may  take  place  through 
the  mitral  valve  without  disease,  as  he  imagines,  they 
in  reality  disprove  the  theory  in  vogue,  and  confirm 
the  doctrine  of  chordae  tendineae  vibrations  as  cause 
of  the  first  sound. 

Dr.  Bristow  remarks  :  **  It  may  almost  be  regarded 
as  an  axiom  in  medicine  that  the  presence  of  a  systolic 
apex-murmur  is  positive  proof  of  regurgitation  through 
the  mitral  orifice.     I   have  not  hesitated  to  adopt  it  in 


DISTURBED   ACTION   OF   THE   HEART.  l8l 

reference  to  the  cases  already  detailed."  The  follow- 
ing are  quotations  from  his  cases : 

Case  1. — There  was  a  distinct  systolic  murmur  aud- 
ible at  the  apex  of  the  heart. 

Post  mortem, — The  aortic  and  mitral  valves  were  per- 
fectly natural. 

Case  II. — There  was  an  increased  area  of  dulness 
in  the  cardiac  region,  and  a  systolic  bruit  loudest  at 
the  apex  of  the  heart. 

Post  mortem. — The  muscular  tissue  and  the  valves 
appeared  perfectly  healthy. 

Case  III. — The  impulse  was  diffused  and  heaving, 
but  not  very  strong.  A  systolic  murmur  was  detected 
at  the  apex  of  the  heart. 

Post  mortem. — All  the  valves  were  healthy-looking. 

Case  IV. — First  sound  at  the  apex  was  flapping  and 
prolonged. 

Post  mortem. — The  valves  were  perfectly  healthy  in 
texture. 

Case  V. — The  cardiac  dulness  was  enlarged,  and  a 
systolic  murmur  was  audible  with  the  heart's  action, 
most  distinct  at  a  point  an  inch  below,  and  internal  to 
the  left  nipple. 

Post  mortem. — All  the  valves  appeared  perfectly 
healthy. 

Case  VI. — There  was  a  distinct  but  not  very  loud 
systolic  murmur,  loudest  in  the  usual  situation  of  the 
apex  of  the  heart. 

Post  mortem. — The  aortic  and  mitral  valves  were  per- 
fectly healthy-looking,  and  doubtless  quite  competent. 

A  tabular  arrangement  like  the  following,  in  classify- 
ing murmurs  acoustically,  may  be  useful : 

Valvular  \  "^^^^^^  obstructive  systolic, 

(all  organic).      l  ^^^^'^  regurgitant  diastolic. 
{  Mitral  regurgitant  systolic. 

Intra-ventricular  j  Organic  functional, 

(more  or  less  functional).    (  Inorganic  functional. 


1 82  DISEASES    OF  THE   HEART  AND   LUNGS. 

These  two  great  divisions  are  made  in  accordance 
with  their  acoustic  differences.  The  sound  in  valvular 
murmurs  is  a  friction-murmur,  that  of  blood  forced 
through  an  aperture.  The  intra-ventricular  murmurs 
are  mostly  and  distinctly  chord-vibrations.  The  con- 
traction of  the  muscular  walls  of  the  heart  and  its  fleshy 
columns,  the  friction  of  rushing  blood  among  the 
chordse  tendinese  and  against  the  tense  mitral  valve, 
being  the  occasion  of  sound  vibrations,  but  is  not  the 
mechanism  of  the  sound  itself  As  great  difference 
exists  between  these  murmurs  as  between  that  of  a 
whisper  and  that  of  the  voice.  The  obstructive  systo- 
lic aortic  may  be  modified  by  irregular  calcifications  in 
the  aortic  valves,  extending  into  the  column  of  forced 
rushing  blood.  In  this  way  a  harsher  character  may 
be  given  to  the  murmur,  or  it  may  even  become  musi- 
cal. Vegetations  also  attached  to  the  orifice  or  valve 
may  be  thrown  into  vibrations  in  the  column  of  blood, 
and  produce  a  musical  murmur,  but  these  are  rare, 
mere  possibilities.  When  musical  murmurs  occur  they 
are  almost  always,  if  not  always,  vibrations  of  the 
chordas  tendineas,  some  of  which  are  under  extraordi- 
nary tension. 

These  sounds  or  murmurs  may  be  illustrated  by  a 
stringed  musical  instrument.  Every  degree  in  quality 
of  murmur  or  sound,  from  the  softest  blowing  up  to  the 
harshest,  sawing,  rasping,  filing,  or  when  the  vibrations 
become  sufficiently  rapid  and  regular,  into  musical 
sounds.  The  use  of  the  term  "  bellows  sound"  by 
Laennec  was  unfortunate  as  applied  to  the  murmurs  of 
the  heart,  and  much  of  the  misunderstanding  of  mur- 
murs and  their  mechanism  is  due  to  it.  It  is  true 
that  it  describes  the  friction-murmur  of  bipod 
forced  through  an  aperture  as  in  aortic  regurgi- 
tation.    It  is  like  the  sound  of  the  air  forced  through 


DISTURBED   ACTION   OF  THE   HEART.  1 83 

the  bellows ;  but  the  bellows-sound  is  not  so  like 
the  friction-murmur  of  blood  forced  through  an 
aperture  as  is  fluid  forced  through  an  elastic  syr- 
inge, in  which  some  obstruction  is  created  by  pres- 
sure upon  the  tube.  But,  to  imitate  the  murmur 
exactly,  a  fissure  should  be  made  in  the  bulb  of  the 
syringe,  and  then  compressing  it  with  force,  the  fluid 
escaping  will  give  the  exact  sound.  The  only  friction- 
sounds  in  cardiac  murmurs  proper  are  where  the  blood 
is  forced  through  apertures  or  past  obstructions ;  it  is 
heard  at  the  aortic  orifice  when  there  is  obstruction,  as 
by  lymph-deposits  upon  the  valve.  It  is  at  first  un- 
complicated, the  simple  gushing  sound.  But  in  time 
the  obstruction  causes  hypertrophy  of  the  left  ventricle, 
which  having  taken  place,  irregular  tension  of  the 
chordae  tendinese  is  the  result,  and  vibrations  out  of 
unison  with  the  first  sound  are  carried  with  the  cur- 
rent of  blood,  and  both  occurring  in  the  systole  are 
mixed  together  and  form  what  is  called  the  blowing 
murmur. 

It  is  now  a  sound  of  mixed  elements,  friction  of  blood 
against  a  solid,  and  vibration  of  strings  under  irregular 
tension.  In  order  to  have  an  intelligent  understanding 
of  these  murmurs  we  must  analyze  them  and  separate 
the  sources  of  sound.  We  are  assisted  in  this  by  localiz- 
ing the  sources.  The  blowing,  sawing,  filing,  rasping 
sounds  have  their  origin  and  cause  within  the  ventricle  ; 
they  are  intra-ventricular.  Dr.  Cammann  called  them 
mitral-non-regurgitant.  They  are  heard  over  the  base 
of  the  heart,  but  always  with  greatest  intensity  at  the 
apex-beat. 

Friction-sounds  are  heard  best  over  the  orifices  or 
in  the  direction  of  the  vibrating  column  of  blood.  The 
aortic  systolic  obstructive  murmur  is  heard  over  the 
aortic  valves,  and  in  the  course  of  the  column  of  blood. 


1 84  DISEASES   OF  THE   HEART   AND   LUNGS. 

The  regurgitant  aortic  diastolic  murmur  is  heard  over 
the  aortic  orifice,  and  to  the  left  and  toward  the  apex- 
beat.  The  mitral  aortic-regurgitant  is  heard  behind  on 
the  left  side  near  the  spine.  In  this  direction  the  blood 
is  forced  in  regurgitation  through  the  mitral  valve  ; 
impinging  first  against  the  auricular  wall,  lying  against 
the  oesophagus,  and  aorta,  and  intervertebral  substance, 
it  is  conducted  directly  into  the  ear,  giving  the  sensation 
of  being  shot  into  it. 

It  may  be  heard  a  short  distance  from  this  point  con- 
veyed through  the  chest-wall.  It  may  be  heard  in  front, 
at  the  apex-beat,  by  conduction  through  the  substance 
of  the  heart,  when  there  are  no  intra-ventricular  mur- 
murs to  destroy  it  or  take  its  place.  The  discovery  of 
this  absolute  sign  of  mitral  regurgitation  belongs  to 
Dr.  Cammann,  and  his  last  professional  thought  was 
given  to  its  consideration.  It  is  one  of  the  most  cer- 
tain of  cardiac  signs.  This  characteristic  murmur, 
heard  in  the  situation  he  has  pointed  out,  is  an  unfailing 
sign  of  mitral  regurgitation.  It  had  been  my  opinion 
that  this  characteristic  murmur  was  never  heard  in 
front  at  the  apex-beat — as  it  certainly  is  not  when  the 
valve  is  diseased,  and  the  loud  intra-ventricular  murmur 
drowns  and  supplants  it. 

But  the  following  case  shows  that  it  may  be  heard 
both  behind  and  before  in  congenital  mitral  insuffi- 
ciency, without  hypertrophy  of  the  heart  and  without 
lymph-deposits  upon  the  valve. 

Case  VII.  (December  12,  1870.)— W.  S.  R.,  New 
York,  aged  twenty-two ;  mason,  living  in  Yorkville  ;  is 
a  fireman  temporarily,  and  was  a  member  of  the  old 
department.  Has  never  been  sick,  except  with  chills 
and  fever.  Sent  for  examination  by  Dr.  Charles  Mc- 
Millan, surgeon  of  the  department.  There  is  a  systolic 
murmur  at  the  apex-beat  accompanying  the  first  sound  ; 


DISTURBED  ACTION   OF   THE   HEART.  185 

it  is  a  soft,  gushing  murmur,  and  can  be  heard  in  the 
chest-wall  more  to  the  left  than  to  the  right  side.  It  is 
heard  also  with  directness  and  greater  intensity  be- 
tween the  seventh  and  eighth  vertebras,  left  side  behind, 
near  the  spine.  The  murmur  is  shot  into  the  ear  when 
placed  over  this  point.  It  can  be  heard  some  distance 
to  the  left,  conveyed  in  the  chest-wall.  It  can  also  be 
heard  over  some  portions  of  the  right  lung  posteriorly, 
at  the  inner  angle  of  the  scapula ;  also  at  the  lower 
angle,  being  a  faintly-conveyed  sound. 

One  year  after,  examined  him  again.  Signs  un- 
changed. This  murmur  has  the  same  quality  in  front 
as  behind.  It  has  none  of  the  vocal  element  of  apex- 
beat  murmurs,  usually  described  as  diagnostic  of  mitral 
regurgitant  murmurs.  Yet  I  have  no  doubt  that  this 
murmur  is  caused  by  mitral  insufficiency,  which  is  con- 
genital, without  hypertrophy  of  the  heart,  and  without 
disease  of  the  mitral  valve. 

A  great  majority  of  cardiac  murmurs,  even  of  those 
accompanying  organic  disease  of  the  heart,  are  in  a 
manner  functional.  That  is,  the  murmurs  are  not 
organic  in  the  same  sense  that  the  valvular  murmurs 
are  ;  which  are  organic  murmurs  because  the  structural 
change  in  the  valve  is  part  of  the  mechanism  of  the 
murmur.  Intra-ventricular  murmurs,  even  when  the 
result  of  structural  change  in  the  heart,  may  be  con- 
sidered functional,  inasmuch  as  that  they  have  their 
mechanism  in  vibrations  of  the  chordae  tendineae,  which 
are  themselves  unchanged  by  any  diseased  action,  but 
simply  vibrate,  giving  out  sound  of  high  or  low  pitch, 
soft  or  harsh,  feeble  or  loud,  according  to  the  degree  of 
tension  of  the  individual  strings,  and  the  force  of  the 
heart's  contraction.  The  cause  of  irregular  contrac- 
tion of  the  heart-muscles  may  be  from  disturbed  nerve 
power,  as  well  as  from  organic  change. 


1 86  DISEASES  OF  THE   HEART  AND   LUNGS. 

Functional  murmurs  proper  may  occur  in  the  healthy 
heart,  are  transient,  passing  away  with  the  subsidence 
of  the  cause,  which  may  be  anasmia,  hypersemia,  sym- 
pathy with  *brain- disease,  stomach,  liver,  or  it  may  be 
from  disorder  of  the  nervous  system,  the  influence  of 
tobacco,  coffee,  tea,  or  any  narcotic  or  stimulant  having 
influence  upon  the  organic  life  of  the  body,  of  which 
the  heart  is  the  centre  and  citadel. 

Functional  murmurs  proper  do  not  signify  danger  of 
sudden  death,  but  nothing  more  alarms  patients  than 
disturbed  action  of  the  heart.  When  the  heart  seems 
to  stop,  and  then  to  turn  over  and  thump  against  the 
chest-wall,  the  sensation  is  not  a  pleasant  one,  even  to  a 
medical  philosopher.  It  is  no  wonder  that  it  creates 
intense  alarm  in  the  lay  patient,  especially  if  accompa- 
nied by  prolonged  palpitation  or  faintings. 

These  conditions  may  be  the  forerunner  of  softening, 
or  fatty  degeneration,  but  they  signify  always  that 
there  is  over-distention  of  the  portal  system,  intermis- 
sion of  the  heart-beat  and  pulse,  may  be  present  for 
years,  and  be  merely  the  result  of  functional  disturb- 
ance from  chronic  indigestion. 

Intermissions  of  the  pulse  have  been  laid  down  in 
books  as  signs  of  heart-disease.  Life-insurance  com- 
panies, in  printed  forms,  make  it  the  duty  of  examiners 
to  reject  as  unsafe  those  who  have  intermittent  pulse. 
It  is  possible  that  this  rule  militates  against  the  interest 
of  the  companies,  and  it  certainly  is  a  source  of  great 
alarm  to  the  rejected  applicant. 

The  sign,  of  itself,  is  no  proof  of  heart-disease,  but  is 
proof  of  indigestion.  It  is  true,  cardiac  disease  is  fre- 
quently a  cause  of  indigestion,  and  thus,  secondarily, 
the  cause  of  irregular  pulse.  But  a  confirmed  dyspep- 
tic is  usually  a  safe  life,  for  he  is  not  likely  to  commit 
indiscretions  in  diet,  as   he  is  continually  warned  to 


DISTURBED  ACTION   OF  THE   HEART.  18/ 

desist  by  functional  disturbances.  Proper  medication 
will  generally  relieve  intermittent  pulse,  even  in  ad- 
vanced cases  of  cardiac  disease. 

A  sedative  dose  of  calomel  will  frequently  set  it  right 
at  once,  and  the  intermissions  will  disappear. 

The  late  Dr.  Samuel  Henry  Dickson  stated  that, 
during  the  first  hours  of  sleep,  children  have  intermit- 
tent pulse,  which  will  disappear  when  they  are  awa- 
kened. This  is  true,  especially  with  those  children  who 
are  allowed  over-stimulating  food,  but,  as  the  night 
passes  on,  and  the  food  becomes  digested,  the  intermis- 
sions cease.  In  the  adult,  the  occasion  of  a  wine- 
dinner,  with  tobacco,  is  often  followed  by  intermittent 
pulse,  especially  during  sleep,  when  the  circulation  is 
sluggish. 

The  cause  of  the  rhythmic  movements  of  the  heart 
is  debatable  ground.  That  it  is  within  the  heart  itself 
can  scarcely  be  questioned,  for,  when  the  heart  of  some 
animals  is  dissevered  from  all  connections,  and  taken 
from  the  body,  it  may  go  on  performing  its  rhythmical 
movements.  Still,  the  quality  and  quantity  of  blood 
influence  them  in  an  unmistakable  manner.  The  fact 
that  shutting  off  supply  of  blood  to  the  structure  of  the 
heart  will  arrest  its  contractions  was  shown  in  1842  by 
Mr.  Erichsen.  Dr.  Brown-Sequard  has  attempted  to 
explain  the  motion  to  be  due  to  the  carbonic  acid  pres- 
ent in  the  venous  blood,  and  Dr.  Radcliffe  has  also 
given  a  similar  explanation. 

The  experiments  of  Dr.  Paget  show  that  the  power 
causing  rhythmical  motion  does  not  reside  in  all  parts 
of  the  heart  alike  ;  that,  in  fact — 

"  If,  for  example,  the  cut-out  heart  (of  any  of  the  am- 
phibia) be  divided  into  two  pieces,  one  comprising  the 
auricles  and  the  base  of  the  ventricle,  the  other  com- 
prising the  rest  of  the  ventricle,  the  former  will  con- 


1 88  DISEASES   OF  THE   HEART  AND   LUNGS. 

tinue  to  act  rhythmically,  the  latter  will  cease  to  do  so, 
and  no  rhythmic  action  can  be  by  any  means  excited  in 
it.  The  piece  of  ventricle  does  not  lose  its  power  of 
motion,  for  if  it  be  in  any  way  stimulated,  it  contracts 
vigorously,  but  it  never  contracts  without  such  an  cxt 
ternal  stimulus,  and  when  stimulated  it  never  contracts 
more  than  once  for  each  stimulus. 

'^  Other  sections  of  the  heart,  and  experiments  of 
other  kinds,  would  show  that  the  cause  of  the  rhyth- 
mic action  of  the  ventricle,  and  probably  also  of  the 
auricles,  so  long  as  they  are  associated  with  it,  and  not 
with  the  venous  trunks,  is  something  in  and  near  the 
boundary  ring  between  the  auricles  and  ventricles ;  for 
what  remains  connected  with  this  ring,  or  grew  with 
a  part  of  it,  in  a  longitudinally  bisected  heart,  retains 
its  rhythm,  and  what  is  disconnected  from  it  loses  its 
rhythm." 

If  we  take  a  merely  material  view  of  the  subject,  no 
doubt  we  have  arrived  at  the  solution  as  nearly  as  we 
ever  will.  But  is  it  useless  or  absurd  to  look  further? 
The  experiments  of  the  great  Harvey  with  the  egg  of 
the  hen  show  that  active  life  remains  inchoate  in  the 
punctum  saliens  or  germinal  spot  until  warmed  into 
active  life.  This  principle  came  into  the  egg  organi- 
zation at  the  time  of  its  fecundation.  Its  first  life- 
motion  is  rhythmical  movement  of  particles  before  any 
portion  of  the  heart's  structure  can  be  seen.  The  little 
red  point  appears  and  disappears  rhythmically,  and 
thus  the  principle  builds  its  house,  the  auricle  being  its 
first  chamber.  The  very  nature  of  this  principle  is 
rhythmical.  Its  special  home  is  in  the  ganglionic  ner- 
vous system,  but  it  pervades  the  whole  body  ;  wher- 
ever there  is  nerve-fibre  accompanying  the  smallest 
capillary — the  vasor-motor — it  is  present.  Aberration 
from  its  normal  life-action  is  disease ;  and  influences, 


DISTURBED   ACTION   OF   THE   HEART.  1 89 

both  outside  and  inside  of  the  body,  make  impressions 
upon  this  life,  helping  to  determine  the  character  of 
the  disease.  Medicines  act  upon  it,  but  their  modus 
operandi  is  a  sealed  mystery.  That  they  are  purga- 
tive, emetic,  stimulant,  sedative,  or  alterative,  we  only 
know  the  fact.  The  heart,  supplied  with  about  three 
hundred  ganglia,  is  the  centre  and  citadel  of  this  life, 
and  its  abnormal  or  disturbed  action  is  sometimes  mys- 
terious evidence  of  both  intrinsic  and  extrinsic  disease. 

Acoustic  properties  of  the  chest  have  not  been  dwelt 
upon  as  their  importance  demands.  The  diagnosis  of 
murmurs  within  the  chest  is  facilitated,  or  otherwise, 
according  to  its  conditions  as  an  acoustic  chamber. 
The  difficulty  of  hearing  signs  in  the  chest  of  a  hunch- 
back is  recognized  ;  it  is  also  a  well-known  fact  that,  as 
the  heart  enlarges,  the  murmurs  grow  weaker,  so  that 
those  which  had  been  once  easily  detected  become  fee- 
ble, or  disappear  altogether.  Still  they  have  been  ac- 
counted for,  it  seems  to  me,  upon  every  other  principle 
than  the  true  one. 

In  Dr.  Cammann's  last  illness,  by  his  request,  I  was 
called  to  examine  him.  After  he  had  explained  to  me 
that  I  would  find  obstructive  and  regurgitant  murmurs, 
of  which  he  had  been  long  cognizant,  and  of  which  he 
explained  the  cause  and  origin,  and  of  their  gradual  in- 
crease, I  found  that  I  could  but  just  hear  the  soft,  feeble 
murmurs  of  aortic  obstruction  and  regurgitation,  but 
intra-ventricalar  murmurs  were  not  heard.  I  told  the 
doctor  that  the  regurgitant  murmur  which  he  had  em- 
phasized in  relating  the  case  was  slight :  "  Yes,"  he 
said,  "it  is  but  a  chink."  Dr.  Peugnet  told  me  that 
when  he  examined  him  at  the  beginning  of  his  illness 
the  murmurs  were  loud  and  easily  heard.  I  felt  morti- 
fied that  my  ear  had  failed  me,  as  I  supposed,  caused 
by  a  long  ride  in  the  cold,  in  an  open  carriage.     The 


IQO  DISEASES   OF  THE   HEART   AND   LUNGS. 

doctor  had  circumscribed  pleuritis  with  effusion  and 
pneumonia.  In  time  the  effusion  was  absorbed,  and 
then  the  murmurs  at  the  apex-beat  were  easily  heard. 

Another  case,  of  which  I  have  no  notes,  in  which  I 
failed  to  make  out  a  murmur  where  it  should  have  been 
heard,  and  which  afterward  returned,  as  the  inter-cur- 
rent pneumonia,  became  convalescent,  also  annoyed  me, 
and  ag-ain  I  blamed  my  ear.  Not  long  afterward  I  saw 
in  the  London  Medical  Times  a7id  Gazette,  or  in  the 
London  Lancet,  the  question,  ''  Why  do  cardiac  mur- 
murs disappear  during  pneumonia  or  pleurisy  ?"  I  felt 
at  once  that  the  cause  of  my  not  hearing  the  murmurs 
more  plainly  in  Dr.  Camman's  case,  as  well  as  in  that  of 
this  other  patient,  was  because  they  were  obscured  by 
some  cause  I  then  did  not  know. 

Other  cases  of  cardiac  murmurs  disappearing  or  be- 
coming obscured  during  the  presence  of  pneumonia  or 
pleuritis  led  me  to  believe  that  it  was  in  accordance 
with  physical  law.  A  patient  with  pleuritic  effusion 
was  sent  to  me  by  Dr.  Otis  for  examination.  I  knew 
from  a  previous  auscultation  that  he  had  aortic  ob- 
structive and  aortic  regurgitant  murmurs.  At  this 
time,  however,  they  could  not  be  heard.  I  wrote  to 
Dr.  Otis,  stating  these  facts,  and  predicting  that  when 
the  effusion  was  absorbed  these  murmurs  would  again 
return,  which  proved  to  be  the  case. 

On  August  27,  1864,  I  saw  Miss  Hall,  matron  of  the 
Home  for  Soldiers'  Children,  in  Fifty-seventh  Street 
near  Eighth  Avenue,  with  Drs.  Charles  McMillan,  J.  L. 
Smith  and  E.  Krakowizer.  There  were  no  heart-mur- 
murs, but  as  all  the  rational  signs  of  cardiac  disease, 
with  increased  area  of  dulness  under  percussion,  signi- 
fied hypertrophy,  it  was  suggested  that  we  should  ex- 
amine her  for  pneumonia,  and,  upon  raising  her  up  and 
listening  behind,  it  w^as  clearly  made  out.     I  then  pre- 


DISTURBED   ACTION   OF  THE   HEART.  I9I 

dieted  that,  when  the  pneumonia  was  well,  we  would 
be  able  to  diagnosticate  her  cardiac  disease.  This  was 
afterward  done,  and  Dr.  J.  L.  Smith  took  notes  of  the 
examination,  and  upon  her  death,  some  months  after- 
w^ard,  was  able  to  verify  the  diagnosis.  He  presented 
the  heart,  with  history,  to  the  Pathological  Society,  and 
a  committee  was  appointed  to  examine  into  the  facts 
concerning  the  disappearance  of  heart-murmurs  during 
the  presence  of  pneumonia  and  pleuritis,  and  to  report. 
If  my  memory  serves  me,  the  committee  reported  in 
substance,  in  the  summer  of  1865,  that  in  some  cases 
observed  in  Bellevue  Hospital,  murmurs  grew  feeble  or 
disappeared  on  the  advent  of  pneumonia  or  pleurisy, 
but  that  it  was  the  opinion  of  the  committee  that  this 
phenomenon  was  owing  to  the  feebleness  of  the  heart 
and  its  frequency,  for  in  the  cases  noticed  the  pulse  was 
120  or  more  per  minute. 

These  reasons  I  had  myself  considered  and  rejected, 
for  at  the  same  time  that  Miss  Hall  was  ill  I  had  an- 
other patient,  O.  B.  H — ,  who  had  had  for  years  a  double 
murmur,  which,  when  attacked  with  pneumonia,  disap- 
peared. His  pulse  ordinarily  was  about  50  in  a  min- 
ute, but  during  the  pneumonia  it  rose  as  high  as  80, 
but  no  higher.  Drs.  Chas.  McMillan  and  J.  L.  Smith 
were  also  both  cognizant  of  the  facts  as  narrated.  The 
philosophical  explanation  of  these  phenomena  occurred 
to  me  during  the  winter  of  1S64-6C,,  with  the  following 
proof  and  illustration.  The  chest  is  a  musical  cham- 
ber, and  may  be  represented  by  a  violin.  When  the  in- 
strument is  tuned  and  in  order,  its  acoustic  qualities 
may  be  considered  as  perfect.  If  a  watch  or  music-box 
be  placed  within  the  violin,  but  not  in  connection  with  it, 
auscultation  will  reveal  the  slightest  jar  or  noise  made 
by  the  works  of  the  watch,  or  bring  out  with  distinctness 
the  low  tones  of  the  music-box.     But  if,  while  the  ear 


Ig2  DISEASES   OF   THE   HEART   AND   LUNGS. 

or  stethoscope  is  still  placed  upon  the  violin,  water  or 
sand  be  poured  into  its  chamber,  the  sounds  of  the  box 
or  watch  will  grow  feeble  or  disappear.  The  low  notes 
of  the  music-box  disappear  entirely,  as  also  does  any 
jarring  of  the  wheels  of  the  watch.  These  phenomena 
are  invariable  because  they  are  the  result  of  acous- 
tic law.  The  application  of  physical  law  to  art  is  to 
render  it  scientific,  and  scientific  medicine  is  the  imme- 
diate professional  want  of  our  time.  If  acoustic  law 
is  applied  to  auscultation  in  physical  diagnosis,  it  will 
remove  it  from  the  domain  of  doubt  or  uncertainty, 
just  so  far  as  its  principles  are  intelligently  applied. 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.    1 93 


X. 

A  NEW   CLASSIFICATION  OF  PHTHISIS   PULMONALIS, 
WITH   REFERENCE   TO    SPECIAL  TREATMENT.* 

The  tendency  of  the  present  time  is  to  re-arrange  and 
to  classify  specific  divisions  of  medical  subjects  in  order 
to  their  thorough  elucidation. 

Not  more  than  a  quarter  of  century  ago  Dr.  Samuel 
Henry  Dickson,  one  of  the  most  accomplished  and  schol- 
arly physicians  of  his  age,  and  representing  the  advanced 
thought  of  his  time,  described  typhus  fever  as  one  dis- 
ease, with  lesions  of  the  head,  with  lesions  of  the  chest, 
and  with  lesions  of  the  abdomen. 

These  divisions  included  those  which  we  now  call 
typhus  fever,  typhoid  fever,  and  typhoid  pneumonia. 
But  it  was  an  intelligent  attempt  to  bring  order  out 
of  chaos. 

Dr.  Murchison  and  others  have  shown  since,  that 
these  divisions  comprise  separate  unities  widely  differ- 
ing in  causation,  history,  physical  signs,  and  in  patho- 
logical changes,  and  with  the  happy  result  of  indicating 
more  rational  and  far  more  successful  methods  of  treat- 
ment. 

That  which  has  been  done  for  the  family  of  typhoid 
diseases  remains  yet  to  be  perfected  in  those  of  phthisis. 

Sydenham  says :  "  There  are  several  kinds  of  con- 
sumption. The  first  mostly  arises  from  taking  cold  in 
winter;  abundance  of  persons  being  seized  with  a 
cough  upon  the  coming  in  of  cold  weather,  a  little 
before   the  winter  solstice,   which    happening  to  such 

*  Archives  of  Medicine,  June,  1879, 


194  DISEASES   OF   THE   HEART  AND   LUNGS. 

as  have  naturally  weak  lungs,  those  parts  must  needs 
be  still  more  weakened  by  frequent  fits  of  coughing, 
and  become  so  diseased  at  length  hereby  as  to  be 
utterly  unable  to  assimilate  their  proper  nourishment. 

"  Hence,  a  copious  crude  phlegm  is  collected.  The 
lungs,  being  hereby  supplied  with  purulent  matter,  taint 
the  whole  mass  of  blood  therewith,  whence  arises  a  pu- 
trid fever,  the  fit  whereof  comes  towards  evening  and 
goes  off  towards  morning,  with  profuse  and  debilitating 
sweats.  And  when  the  lungs  lose  their  natural  tone, 
tubercles  ordinarily  breed  therein.  .  .  .  When  this  dis- 
ease is  confirmed,  it  for  the  most  part  proves  incurable." 
Is  not  this  a  good  description  of  consumption  for  one 
two  hundred  years  old  ? 

Laennec  and  his  followers  classed  everything  in  pul- 
monary phthisis  as  tubercular.  "  This,"  he  says,  "  I 
think  is  the  only  kind  of  phthisis  which  we  should  ad- 
mit, unless,  indeed,  it  were  the  phthisis  nervosa  and 
the  chronic  catarrh  simulating  tuberculous  phthisis." 

Broussais  held  with  the  ancients  that  phthisis  may  re- 
sult from  inflammation,  but  Laennec  charged  him  with 
doing  so  by  assertion  and  ratiocination,  however,  rather 
than  by  facts.  The  tide  of  Laennec's  well-earned  fame 
has  floated  some  errors  down  to  our  own  time,  espe- 
cially one  which  throws  contempt  upon  the  observa- 
tions of  his  eminent  compeer. 

Sir  James  Clark,  Sir  John  Forbes,  and  other  English 
writers  who  had  learned  immediately  from  Laennec 
and  Louis,  followed  strictly  in  the  line  of  the  great 
French  leaders,  and  created,  so  to  speak,  a  tubercular 
public  opinion.  But  now  a  wider  and  more  catholic 
view  is  being  taken  by  English  and  American  physi- 
cians who  are  conservative  and  practical  rather  than 
hypothetical. 

Dr.  Andrew  Clark,  of  London,  in  a  lecture  at  Bellevue 


NEW   CLASSIFICATION   OF  PHTHISIS    PULMONALIS.    I95 

Hospital  last  autumn,  and  which  was  reported  in  the 
New  York  Medical  Record,  divided  phthisis  into  three, 
as  he  said,  natural  classes,  viz..  Tubercular,  Catarrhal 
Pneumonia,  and  Fibroid.  Tubercular  and  fibroid  rep- 
resent great  natural  divisions,  and  are  descriptive 
of  great  pathological  conditions  and  differences.  In 
one  there  results  death  of  tissues,  in  the  other  func- 
tional incapacity.  In  both  there  are  cough,  expecto- 
ration, and  wasting — and  there  may  be  haemoptysis,  but 
even  in  these  particulars,  common  to  both,  they  are  in- 
dividually different  as  they  are  also  in  their  grander 
distinctions. 

Indeed,  they  are  opposing  diseases  of  the  same  organ, 
which,  did  they  not  frequently  coalesce,  producing  new 
diseases  by  their  combinations,  would  be  described 
always  as  distinct. 

Niemeyer,  leading  the  modern  school  of  pathological 
physicians,  includes  all  these  under  the  term  Catarrhal 
Pneumonia,  which  name,  I  shall  endeavor  to  show  far- 
ther on,  is  not  fully  descriptive  of  the  cause  nor  of  the 
morbid  results. 

The  following  classification  is  one  which  my  clinical 
experience,  confirmed  by  autopsical  examinations,  has 
led  me  to  adopt : 

FIRST   CLASS,    OR   TUBERCULAR   PHTHISIS. 

First  Division. — Uncomplicated  Tubercular  Lung. 
Second  Division. — Lung  with  Tubercular  Adherent 
Pleurse. 

SECOND    CLASS,   OR   FIBROID    PHTHISIS. 

First  Division.  —  Adherent  Pleurae,  with  Fibroid 
Lung. 

Second  Division. — Adherent  Pleurae,  ^yith  Tuber-. 
Gulated  Fibroid  Lung, 


196  DISEASES    OF  THE   HEART   AND   LUNGS. 

This  classification  may  cover  the  whole  ground — in- 
cluding accidents  and  complications. 

First  Class,  First  Division. 

Uncomplicated  Tubercular  Lung. — Tubercular  con- 
cretions and  cavities  in  the  lung  without  adherent 
pleurse  or  fibroid — sacculated  tubercle — latent  phthisis. 

This  form  of  phthisis  is  rare. 

Louis'  says :  ''  Nothing  was  so  frequent  as  the  ad- 
hesions of  the  lungs  to  the  pleuras,  for  in  a  hundred 
and  twelve  cases  there  onl}^  existed  one  in  which  the 
two  lungs  were  free  in  the  whole  of  their  extent.  We 
have  only  found  the  right  lung  completely  without  adhe- 
sions eight  times  ;  the  left  only  seven,  and  in  these  cases 
there  were  either  no  tuberculous  excavations,  or  only 
those  of  very  limited  dimensions." 

Laennec  and  Louis  include  all  those  cases  which  are 
obscure  in  diagnosis,  especially  in  the  earlier  stages, 
under  the  term  latent  phthisis.  *'  These  differences  in 
the  order  and  duration  of  the  morbid  phenomena  do 
not  interfere  with  the  regular  progress  of  the  disease — 
do  not,  so  to  express  ourselves,  alter  its  physiognomy ; 
but  there  are  instances  when  its  characters  are  so  com- 
pletely modified  that  its  recognition  is  impossible  be- 
fore its  progress  is  considerable ;  it  is,  in  fact,  latent  for 
a  longer  or  shorter  period.  At  other  times  it  assumes 
the  form  and  progress  of  acute  diseases,  its  different 
periods  seem  confounded  together,  and  the  diagnosis 
is  not  less  obscure  than  the  opposite  condition."  * 

The  early  history  of  the  first  division  of  tubercular 
phthisis  is  generally  overlooked  on  account  of  the  ob- 
scurity of  the  physical  signs  and  symptoms,  owing  to 

*  Phthisis:  by  Louis.    Chap.  VIIL,  372,    (Translated  by  Chas,  Cowan, 
M.D.,  Washington,  1876.) 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.    197^ 

the  fact  that  there  are  no  adhesions  to  convey  the  sounds 
of  morbid  changes  in  the  lung-  into  the  chest-wall  for 
easy  recognition ;  the  first  observed  evidences  of  the 
disease  being  those  connected  with  the  formation  of  a 
cavity. 

Laennec  says  of  latent  phthisis :  "  It  very  seldom  hap- 
pens that  phthisis  is  latent  through  its  whole  course  ; 
but  it  is  by  no  means  rare  to  meet  with  cases  in  which 
the  characteristic  symptoms  show  themselves  only  a 
few  weeks,  or  even  days,  before  death ;  and  which  had 
been  previously  mistaken  for  diseases  of  quite  a  differ- 
ent nature."  * 

These  cases  were  evidently  according  to  our  classifi- 
cation —  Class  First,  Division  First  —  uncomplicated 
tubercular  phthisis,  until  "the  characteristic  symp- 
toms" showed  themselves  "a  few  weeks  or  even  days" 
before  death,  when  they  came  under  the  second  division 
of  tubercular  lung  with  adherent  pleurae.  Laennec  nor 
Louis  knew  anything  about  the  laws  of  acoustics,  nor 
did  they  know  of  residual  air,  and  consequently  they 
lacked  the  elementary  knowledge  for  correct  diagnosti- 
cation  of  uncomplicated  tubercular  lung. 

It  is  not  wonderful  that  these  early  auscultators  to 
whom  we  owe  so  much  should  have  been  unable  to 
diagnosticate  uncomplicated  tubercular  lung,  for  there 
were  no  adherent  pleurae  for  the  ready  conduction  of 
sound — telephoniftg,  as  it  were,  from  the  interior  of  the 
lung  into  the  chest-wall.  Even  now  the  auscultator 
who  does  not  recognize  the  diagnostic  value  of  true  re- 
spiratory murmur  cannot  appreciate  the  delicate  but 
absolute  sign  of  centric  tubercular  concretions  nor  of 
centric  pneumonia,  which  is  simply  to  comprehend  the 
fulness  or  absence  of  true  respiratory  murmur,  without 

*  Forbes'  Translation,  p.  327. 


19^  DISEASES   OF  THE   HEART  AND   LUNGS. 

which  the  evidence  of  the  condition  of  the  interior  of 
the  lung  entirely  escapes  them. 

The  predisposing"  cause  of  uncomplicated  tubercular 
consumption  is  a  strong  proclivity  from  inherited  ten- 
dency. It  occurs  most  frequently  in  early  adult  life  or, 
in  middle  age,  and  its  immediate  cause  is  local  or  sys- 
temic irritation.  Acute  tuberculosis  occurs  in  children, 
at  the  periods  of  dentition,  at  puberty,  and  in  middle  life. 
The  relation  of  acute  tuberculosis  to  tubercular  con- 
dition of  the  lungs,  to  my  mind,  is  not  absolutely  clear, 
but  clinically  children  liable  to  head  troubles  in  in- 
fancy, if  they  live  to  adult  age,  may  have  tubercular 
phthisis.  Both  in  children  and  at  adolescence  the  mani- 
festations of  tubercular  invasions  may  occur  in  persons 
of  full  habit,  with  abundance  of  adipose. 

At  the  first  thought  this  seems  incongruous,  for  tu- 
bercle is  the  feeblest  of  neoplasms  and  runs  a  rapid 
course  of  degeneration  ;  but  we  must  remember  that 
adipose  is  not  of  itself  a  sign  of  strength,  but  in 
tubercular  cases  it  may  exist  at  the  period  of  inva- 
sion, connected  with  a  marked  prostration  of  vital 
power.  Should  a  case  be  under  skilled  observation 
before  the  appearance  of  cavities,  it  may  be  noticed 
that  there  is  deficienc}''  of  true  respiratory  murmur, 
especially  over  the  site  of  forming  concretions,  while 
at  the  same  time  there  is  slightly  raised  pitch  under 
percussion.  There  are  no  rhonchi,"*  rales,  sibilus,  or 
sonorous,  and  possibly  no  cough.  But  just  so  soon  as 
the  nodules  or  encysted  tubercle  begin  to  soften,  there 
will  be  prostration,  rise  of  temperature,  quickened  pulse 
and  hurried  breathing — perhaps  cough  and  slight  ex- 
pectoration if  the  concretions  should  be  near  bronchial 
tubes,  but  when  the  abscess  opens  into  a  bronchus  there 
may  be  expectoration  of  characteristic  matter,  and  there 
may  be  fatal  pneumorrhagia,  depending  upon  the  ero- 


NEW   CLASSIFICATION  OF  PHTHISIS   PULMONALIS.    I99 

sion  of  an  artery  occurring  at  the  same  time.  Then  for 
the  first  time  the  physical  signs  of  a  cavity  are  discov- 
erable, but  they  are  by  no  means  so  plain  as  when  there 
are  interpleural  adhesions  and  fibroid  lung.  Healthy 
lung  structure  is  a  poor  conductor  of  sound ;  but  an 
attentive  ear  will  discover  a  low  note  of  amphoric  char- 
acter, especially  in  expiration.  Should  the  cavity  be 
large  and  connected  with  a  large  bronchus,  there  may 
be  gurgling  when  it  contains  fluid.  Coughing"  and  ex- 
pectoration are  never  excessive  as  they  may  be  in 
fibroid  phthisis.  Wasting  and  loss  of  weight  commence 
to  rapidly  increase  after  the  occurrence  of  cavities,  as 
do  also  hectic,  night-sweats,  loss  of  appetite,  etc.  Louis 
gives  two  varieties  of  the  latent  form  of  phthisis.  One 
rapid  in  its  course,  ending  in  a  few  weeks  without  any 
arrest  in  progress,  while  the  other  may  linger  and  for 
a  time  give  some  hope  of  recovery.  I  have  seen  both 
varieties.  One,  in  which  there  was  an  arrest  of  pro- 
gress of  disease  in  the  lung,  died  with  marked  signs  of 
meningeal  tuberculosis. 

Laennec  also  refers  to  latent  phthisis  and  acute  phthi- 
sis, but  not  in  so  clear  a  manner  as  Louis,  and  without 
detailing  physical  signs  or  post-mortem  examinations. 
Except  incidentally  in  one  case,  *'  a  girl,  eighteen  years 
of  age,  who  died  in  the  hospital  Cochin,  without  any 
emaciation,  or  other  symptom  except  those  of  a  severe 
feverish  catarrh  of  less  than  a  month's  duration.  Upon 
examining  the  body,  the  lungs  were  found  filled  with 
tubercles  more  or  less  softened,  of  a  size  almost  uniform, 
and  none  less  than  a  filbert  or  almond."  *  This  case 
was,  no  doubt,  one  of  uncomplicated  tubercular  lung. 

Rindfleish  says  :  *'  That  tuberculous  phthisis  is  only 

*  Laennec.     Forbes'  Trans.,  4th  edition,  p.  328  and  329. 


200  DISEASES   OF  THE   HEART  AND   LUNGS. 

a   combination  of  scrofulous  inflammation  and   tuber- 
cles." * 

"  Nodules  as  large  as  a  pea,  or  even  a  walnut,  are  not 
uncommon."  f 

Treatment. — The  early  management  of  a  case  is  in  its 
prevention.  Scrofulous  diathesis  indicates  that  the  in- 
dividual should  be  kept  under  the  best  hygienic  influ- 
ences, out-door  exercise,  pure  air,  and  appropriate  food, 
and  that  any  local  or  systemic  source  of  irritation  should 
be  removed.  I  consider  chloride  of  ammonium  as  a 
preventive  as  well  as  a  curative  agent  of-  very  great 
value.  It  may  be  used  in  baths,  by  inhalation  and  by 
enema,  as  well  as  by  the  stomach.  Dissolved  in  bay 
rum  it  is  a  pleasant  sponge-bath  with  a  flannel  cloth 
night  and  morning.  By  inhalation  in  all  the  catarrhal 
conditions  of  the  nasal  and  upper-air  passages.  By 
enema  in  threatened  meningitis  of  children,  and  by  the 
stomach  in  deep-seated  "  colds." 

Should  the  disease  have  commenced,  cod-liver  oil, 
tonics,  aids  to  digestion  generally,  change  of  air  and 
scene  in  addition  to  hyg^ienic  conditions  and  chloride 
of  ammonium  may  be  beneficial.  Also,  digitalis  sus- 
tains the  action  of  the  heart  when  enfeebled  ;  atropia 
control  night-sweats ;  quinine  and  arsenic  are  anti-peri- 
odic, and  may  be  adjuvant  according  to  individual  in- 
dications. 

I  have  no  doubt  also  that  iron  and  iodine  may  be  of 
great  value  in  purifying  and  enriching  the  blood. 

Recent  excavations  may  be  kept  at  rest,  preventing 
extension  of  disease  and  of  pneumorrhaghia  by  strap- 
ping the  affected  side  with  elastic  adhesive  plasters. 

Small  blisters  frequently  applied  over  and  around  the 

*Ziemssen,  vol.  V.,  p.  635,  American  edition. 
f  lb.  id.  p.  642. 


NEW   CLASSIFICATION   OF  PHTHISIS   PULMONALIS.   201 

region  of  excavations  assist  in  arresting  progress  of 
disease. 

Stimulants,  when  they  promote  sleep  and  digestion, 
should  be  taken  at  meals  and  at  bed-time.  Food  should 
be  abundant,  easily  digestible,  varied,  and  moderately 
stimulating. 

Forced  expansion  of  the  chest  when  nodules  are  soft- 
ening, or  after  an  excavation  has  been  formed,  must,  of 
necessity,  be  avoided.  But  when  the  danger  of  hem- 
orrhage has  passed,  it  may  be  gradually  resumed. 
A  fatal  hemorrhage  rarely  takes  place  after  a  cavity 
is  a  week  old.     Eroded  arteries  contract  speedily. 

Inhalations  of  medicated  vapor  may  soothe  irritation 
in  the  upper  bronchias,  prevent  ulceration  in  the  lar3mx 
and  trachea,  and  may  even  reach  excavations  opening 
into  large  bronchise.  A  certain  amount  of  medication 
may  enter  the  system,  especially  chloride  of  ammoni- 
um, but  we  must  remember  that  the  residual  air  resists 
the  entrance  of  irritating  vapor  into  the  true  respira- 
tory system  ;  hence,  there  is  generally  disappointment 
where  much  benefit  has  been  anticipated. 

Second  division  of  the  first  or  tubercular  class.  Tuber- 
cular nodules  and  cavities  following  pleural  adhesions. 

The  only  difference  of  the  second  division  of  the  tu- 
bercular class  from  the  first  is,  that  it  commences  with 
plastic  exudation  within  the  pleuras — sacculated  or 
nodular  phthisis  very  soon  following.  This  division  is 
larger  than  the  uncomplicated  tubercular,  and  is  remark- 
able for  the  frequency  in  which  it  is  terminated  by 
fatal  accidents,  pneumorrhagia  and  hydropneumotho- 
rax.  These  accidents  may  occur  in  the  first  division  as 
well  as  in  the  second  or  tuberculated  division  of  fibroid 
phthisis,  but  in  an  experience  of  thirty  years  I  do  not 
remember  a  single  case  of  fatal  pneumorrhagia  occur- 
ring in  any  but  in  the  second  division  of  tubercular 


202  DISEASES   OF   THE   HEART  AND   LUNGS. 

phthisis,  at  least  none  others  were  verified  by  post-mor- 
tem examinations. 

In  the  first  division  of  the  first  class  the  occurrence 
of  tubercle  is  apparently  spontaneous.  If  pleuritic  ad- 
hesions afterward  occur,  they  are  accidental,  and  ap- 
pear near  the  end  of  the  disease  ;  but  in  the  second 
class  adhesions  precede  and  seem  to  excite  tubercular 
deposits.  I  am  fully  aware  that  this  fact  cannot  be 
fully  appreciated  except  by  those  capable  of  recogniz- 
ing the  initial  stage  of  interpleural  plastic  exudation.* 

However,  if  my  position  is  correct,  the  immediate  re- 
absorption  of  the  plastic  exudation  may  prevent  tuber- 
cular deposits  and  its  dangerous  liabilities. 

The  following  history  in  fatal  cases  usually  obtains  : 
Plastic  exudation  takes  place  within  the  pleurae,  over 
the  upper  half  of  the  lungs,  and  tubercular  concretions 
mostly  centric  are  formed,  and  pass  to  the  period  of 
softening.  Earlv  in  the  disease  one  or  more  open  into 
a  bronchus,  and  if  a  branch  of  the  pulmonary  artery 
passing  through  the  abscess  opens  at  the  same  time, 
instantly  blood  will  fill  the  air  passages  in  that  side  of 
the  chest,  and,  rising  into  the  trachea,  run  over,  fill- 
ing the  air  passages  in  the  other  side  of  the  chest — a  few 
mouthfuls  of  blood  are  expectorated,  when  the  mouth 
and  nose  fill  with  frothy  blood,  the  patient  strangles — 
is  literally  drowned  in  a  few  minutes. f 

The  fatal  occurrence  of  pneumorrhagia  is  always  a 
surprise  to  the  physician  as  well  as  to  the  patient  and 
his  friends,  as  the  first  indications  of  danger  are  only 
recognized  when  it  is  too  late.  The  formation  of  tuber- 
cular nodules,  centric,  in  otherwise  healthy  lungs,  un- 

*  See  Dr.  Brown-Sequard's  Archives  of  Scietitific  and  Practical  Medi- 
cine, March,  1873;  the  Medical  Record,  May  25,  1878. 

f  Case  viii.,  Physical  Signs  of  Interpleural  Pathological  Processes. 
Medical  Record,  May  26,  1878. 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.    203 

derneath  adhesions  and  thickened  pleuras,  cannot  be 
easily  diagnosticated,  for  there  are  no  obvious  physical 
signs. 

Post-mortem  examinations  show  a  few  tubercular 
concretions,  mostly  central,  near  blood-vessels  and 
bronchige,  one  or  two  of  which  have  opened  into  a 
bronchus  and  into  a  branch  of  the  pulmonary  artery  at 
the  same  time,  and  the  bronchial  tubes  are  filled  with 
blood. 

Should  a  softening  nodule  open  into  the  pleuras,  let- 
ting in  air  and  fluid,  we  would  have  hydropneumo- 
thorax.  This  accident  occurs  suddenly,  causing  great 
pain  and  dyspnoea.  Sometimes  the  patient  dies  from 
the  shock,  or  he  may  linger  a  few  days  ;  occasionally 
months.     Some  have  recovered. 

The  diagnosis  is  easy.  The  sudden  pain  and  dysp- 
noea direct  attention  to  the  affected  side,  and  the 
tympanitic  resonance  under  percussion,  with  amphoric 
respiration  and  metallic  tinkling,  are  decisive. 

Treatment  will  consist  in  immediately  strapping  the 
affected  side  with  elastic  adhesive  plasters,  relieving 
pain  and  controlling  inflammation.  If  the  amount  of 
fluid  escaping  into  the  pleural  cavity  is  small,  the  open- 
ing through  the  pleura  may  be  closed,  the  fluid  ab- 
sorbed, and  the  patient  live. 

The  consideration  of  both  divisions  of  the  first  or 
tubercular  class  fully  justifies  the  popular  belief  in  the 
fatality  of  consumption.  Fortunately  the  number  is 
much  less  than  that  of  the  fibroid  class,  which  is  amena- 
ble to  treatment. 

SECOND     CLASS. — FIBROID. 
First  Division. — Adherent  Pleurce,  with  Fibroid  Lung, 

This  division  represents  a  disease  entirely  opposed 
to  that  of  the  first  division  of  the  tubercular  class. 


204  DISEASES   OF  .THE   HEART  AND   LUNGS. 

In  this  there  is  loss  of  function  only,  in  that  necrosis 
of  tissue,  with  loss  of  substance. 

Many  times,  doubtless,  pure  fibroid  has  been  mis- 
taken for  tuberculated  fibroid  phthisis,  the  second  di- 
vision of  this  class,  on  account  of  the  gurgling  rales 
being  misinterpreted  as  signs  of  cavernules  in  the 
lungs. 

The  physical  signs  of  plastic  exudation  are  soft,  tear- 
ing, crepitant  and  sub-crepitant  rales  near  the  ear — not 
more  than  five  or  six  lines  distant — which  are  often  pres- 
ent without  any  expectoration  or  cough,  and  which 
are  heard  in  the  same  place  from  day  to  day. 

If  they  were  caused  by  mucus  in  the  bronchial  tubes, 
they  would  almost  necessarily  be  accompanied  by  ex- 
pectoration and  cough  ;  they  would  be  at  different  dis- 
tances from  the  ear — never  so  near,  and  would  change 
their  locality  and  quality  at  each  examination. 

I  believe  that  nine  tenths  of  all  forms  of  phthisis  com- 
mence with  interpleural  plastic  exudation,  which  is  re- 
movable, when  fresh,  by  proper  management. 

In  consequence  it  is  of  the  utmost  importance  that 
an  early  diagnosis  should  be  made,  in  order  that  judi- 
cious but  simple  management,  aided,  if  necessary,  by 
positive  treatment,  may  clear  up  all  signs  of  the  exuda- 
tion, and  in  accomplishing  this,  arrest  the  tendency  to 
phthisis,  diminishing  the  number  of  victims  of  the  most 
common  and  the  most  fatal  of  diseases. 

The  inherited  proclivities  in  fibroid  phthisis  are 
gout,  gouty  rheumatism  and  syphilis — factors  of  vital 
depression  favorable  to  plastic  exudation. 

But  many  times  the  prochvity  is  acquired,  where  the 
heredity  is  of  health.  Anxiety  of  mind,  mental  or  vital 
depression  long  continued,  may  inaugurate  a  tendency 
to  plastic  exudation  in  the  most  healthful  organization. 
Instances  of  a  surviving  husband  or  wife,  after  long 


NEW   CLASSIFICATION   OF  PHTHISIS   PULMONALIS.    205 

watching  at  the  bedside  of  one  dying-  with  phthisis,  be- 
coming consumptive  are  not  unusual. 

So  frequent  is  this  the  case  that  the  question  of  the 
transmissibility  of  phthisis  has  been  mooted  ;  but  a 
conclusive  answer  is,  that  whatever  may  have  been  the 
character  of  the  lingering  disease  of  the  first,  the 
second  resulting,  always  begins  with  plastic  exudation. 

Mental  Depression. — Students,  men  of  exciting  busi- 
ness, and  lovers,  when  unsuccessful,  are  liable  to  inter- 
pleural exudation,  which  may  be  the  beginning  of 
phthisis.  Soldiers  after  a  defeat  are  liable  to  phthisis 
or  typhoid  fever. 

Vital  Depression. — Syphilis,  or  masturbation  in  those 
just  arriving  at  adult  age,  smallpox,  or  other  of  the 
exanthematous  diseases,  a  badly  managed  pleurisy 
or  pleuropneumonia,  malaria,  a  wasting  ulcer,  a  capital 
operation  in  surgery  may  be  followed  by  plastic  exuda- 
tion, which  may  end  in  consumption. 

The  depressing  causes  are  so  numerous  that  it  is  a 
wonder  that  these  serious  consequences  from  plastic 
exudations  are  not  oftener  observed.  The  exudation 
is  no  doubt  much  more  frequent  than  we  are  aware,  as 
many  times  it  is  immediately  re-absorbed,  and  at  other 
times,  although  becoming  organized,  it  may  be  of  such 
limited  extent,  and  so  placed,  as  to  remain  innocuous 
during  life.  The  exudation  is  a  makeshift,  as  it  were, 
of  nature,  and  it  is  only  when  she  is  unable  to  remove  it 
again  that  it  becomes  a  source  of  inconvenience  or  of 
danger.  If  not  re-absorbed,  it  becomes  organized,  and 
contracts  according  to  a  natural  law.  The  effect  of 
which  upon  the  pulmonary  pleura  is  to  press  it  down 
on  the  air  sacs  immediately  underneath,  closing  them 
and  arresting  the  cap-illary  circulation,  which  is  then 
thrown  back  upon  its  two  sources  of  pulmonary  supply 
that  of  the  pulmonary  artery  and  that  of  the  bronchial, 


2o6  DISEASES    OF  THE   HEART  AND   LUNGS. 

through  the  nutrient  arteries.  The  obstruction  to  the 
circulation  of  the  blood  from  the  pulmonary  artery  is 
not  of  much  importance,  but  that  of  the  capillaries  of 
the  nutrient  arteries  seriously  interferes  with  the  cir- 
culation through  the  bronchial  arteries.  The  nutrient 
arteries  of  the  true  respiratory  system  of  the  lungs  are 
derived  from  the  bronchial.  They  have  no  venas 
comites  to  return  their  blood  to  the  right  heart  for  re- 
aeration,  as  all  other  arteries  of  the  body  have.  The 
blood  which  they  carry  to  the  tissues  of  the  true  respira- 
tory system  for  its  nutrition  is  re-aerated  as  it  passes 
through  the  capillaries  into  the  radicles  of  the  pulmo- 
nary vein — never  becoming  venous  in  character. 

This  anatomical  peculiarity  is  the  key  to  many  other- 
wise inexplicable  phenomena  of  diseases  of  the  lungs 
and  of  the  pleuras.  It  explains  bronchorrhagia  and 
bronchorrhoea.  As  before  said,  fibrination  having  taken 
place  upon  the  pulmonary  pleura,  and  contracting,  the 
blood  in  the  nutrient  arteries,  is  "  backwatered,"  so  to 
speak,  upon  the  bronchial,  whose  only  relief  is  trans- 
fusion through  the  mucous  membrane,  of  blood,  fibrine, 
serum  or  mucus. 

Consequently  the  indications  are  that  the  bronchor- 
rhagia or  bronchorrhoea  following  should  be  treated  as 
effects,  and  not  as  diseases.  They  are  the  natural  re- 
sults of  the  capillary  obstruction.  Such  bronchorrhoea 
is  different  from  primary  catarrh,  inasmuch  as  its  pri- 
marv  cause  is  not  in  the  mucous  membrane,  but  far  re- 
moved  from  it.  Also  fibrination  within  the  pleurse  alone 
is  not  pneumonia,  as  has  been  mistakenly  diagnosti- 
cated. 

A  careful  physical  examination  will  show  that  at  this 
stage  all  the  changes  that  have  taken  place  are  within 
the  pleuras.  For  these  pregnant  reasons  I  cannot 
accept  the  term  catarrhal  pneumonia  as  descriptive  of 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.    207 

its  pathological  processes.  All  of  these  signs  and  con- 
ditions are  the  accumulating  results  of  obstruction  of 
the  capillaries  immediately  subtending  the  pulmonary 
pleurae. 

From  time  to  time  fibrination  progresses  induced  by 
slight  causes,  until  the  patient  yields  to  the  crippling 
process  of  contraction,  stoops  forward,  with  hurried 
breathing  and  spasmodic  cough.  Old  adhesions  are 
reinforced  by  new  exudation  caused  by  colds,  fatigue, 
emotion  or  ''worry." 

The  second  stage  of  the  first  division  now  com- 
mences when  the  inflammatory  process  begins  to  ex- 
tend into  and  through  the  lung  itself,  and  portion  after 
portion  of  the  true  respiratory  system  becomes  involved 
in  the  contracting  fibroid.  The  heart  and  lungs  are 
displaced  upwards,  downwards  or  sideways,  or  are 
bound  to  the  chest-wall.  Cardiac  murmurs  result  which 
may  deceive  the  physician  into  making  an  error  in  diag- 
nosis of  heart  disease.  The  heart  struggles,  palpitates, 
sometimes  hypertrophies  or  dilates  and  fails  to  properly 
carry  on  the  circulation,  stasis,  increased  fibrination, 
continually  recurring,  spasmodic,  strangling,  almost  suf- 
focating cough,  fill  up  a  picture  of  a  pitiable  condition. 
Autopsies  confirm  the  diagnosis  in  a  remarkable  man- 
ner. Adhesions  within  the  pleurse  fasten  the  lung  to 
the  chest- wall,  sometimes  to  the  mediastinum,  the  peri- 
cardial sac  to  the  lungs,  and  all  are  drawn  out  of  their 
normal  position  until  the  apex  of  the  heart  has  been 
found  on  a  level  with  the  lower  border  of  the  fourth 
rib.* 

The  earliest  physical  signs  of  fibroid  are  simply 
those  of  plastic  exudation  within  the  pleuras.  The  per- 
cussion note  is  slightly  flat,  and  raised  in  pitch  as  if 

*  Case    IV.,  Phys.    Signs,   of   In.    PL   Path.    Process.       The  Medical 

Record,  May  15th,  1878, 


208  DISEASES   OF   THE   HEART   AND    LUNGS. 

parchment  or  paper  were  spread  over  the  chest-wall. 
The  rales  are  fine,  soft,  moist,  tearing.  It  requires  a 
practised  ear  sometimes  to  discover  these  delicate  signs, 
but  even  a  beginner  in  auscultation  will  notice  that  the 
respiration  is  harsher  over  some  one  region  of  the 
affected  chest  than  another ;  let  him  fix  his  attention  in 
listening  to  this  rough  respiration,  and  fill  his  own 
lungs  at  the  same  time  and  in  the  same  way  as  does  the 
patient,  and  after  a  little  while  he  will  be  able  to  ana- 
lyze this  roughness,  and  find  that  it  is  made  up  of  innu- 
merable moist,  soft  rales,  very  fine  and  very  frequent. 
At  the  same  time  he  may  hear  the  true  respiratory 
murmur,  when  it  exists,  just  beyond  the  interpleural 
rales,  with  just  as  much  certainty  in  measuring  the 
distance  as  he  could  do  it  by  sight,  welling  up  under 
the  pleurae  at  the  end  of  a  full  inspiration  like  the  dis- 
tant roar  of  the  sea.  When  he  finally  hears  these  rales 
and  distinguishes  at  the  same  time  the  true  respiratory 
murmur,  he  will  be  convinced  of  two  important  facts,' 
that  there  is  lymph  exudation  within  the  pleurse  and 
that  the  lungs  are  free.  In  time,  these  soft,  almost  un- 
recognizable rales  become  more  distinct,  even  dry  and 
crackling,  and  then  all  doubt  of  their  existence  is 
cleared  up. 

There  may  be  an  abundance  of  rales  with  neither 
cough  nor  expectoration ;  but  unless  the  exudation  is 
re-absorbed  they  will  begin  in  time ;  at  first  viscid 
mucus,  colorless  or  slightly  tinged  with  blood,  but 
afterwards  becoming  profuse  and  assuming  a  greenish 
hue. 

The  dyspnoea  is  frequently  out  of  all  proportion  to 
the  amount  of  pathological  results  in  the  pleurse  or  of 
the  congestion  of  the  lungs. 

If  the  serious  mistake  has  been  made  of  considering 
the  early  signs  of  plastic  exudation  as  those  of  catarrh 


NEW   CLASSIFICATION   OF  PHTHISIS   PULMONALIS.   209 

or  of  bronchitis,  strong-  adhesions  may  result  and  be- 
come a  point  of  irritation,  which  may  continually  induce 
new  exudation  and  increased  disability. 

The  physical  signs  of  firm  adhesions  are  greater  flat- 
ness under  percussion,  and  perhaps  a  shade  of  dulness 
over  areas  of  thickened  pleura  or  of  condensation  of 
lung,  with  a  great  variety  of  rales,  fine,  dry,  moist, 
coarse,  or  a  combination  of  all  of  these.  The  rational 
signs  are  distressing  dyspnoea ;  spasmodic  coughing, 
with  copious  expectoration;  irregular  palpitation  of 
the  heart ;  temperature  varying  from  natural  to  38.9°C. 
40°  C;  variable  appetite  ;  sometimes  sleeping  quietly 
when  lying  down ;  in  other  cases  catching  what  sleep 
they  can  in  an  arm-chair,  or  sitting  up  and  leaning  for- 
ward in  bed  ;  progressive  emaciation  and  debility,  until 
a  new  cold,  greater  hyperasmia,  fresh  exudation,  and  the 
life  is  closed  out.  Louis  notes  that  in  autopsies  it  was 
found  that  fresh  plastic  exudation,  occurring  in  the  last 
days  of  exhausted  vitality,  was  evidence  of  debility. 
No  doubt  it  is  so  at  the  commencement  as  well  as  at 
the  end  in  phthisis  cases. 

Treatment  of  first  division  of  the  fibroid  class  is  an 
easy  problem  at  the  beginning,  but  grows  more  diffi- 
cult every  day  of  its  after  existence.  Organization  may 
take  place  very  soon  after  exudation,  but  generally 
appropriate  management  will  cause  its  speedy  removal. 
Even  when  the  exudation  is  some,  weeks  or  months 
old,  positive  treatment  will  soon  clear  up  the  evidences 
of  disability  and  disease.  Regulated  or  systematic  ex- 
pansion of  the  chest  in  the  open  air,  with  appropriate 
food,  are  of  the  first  importance.  Walking,  or  riding 
on  horseback,  in  the  country,  and  habitually  filling  the 
lungs  and  holding  the  breath  a  little  more  and  a  little 
longer  than  usual,  with  milk  diet  in  abundance,  is  gen- 
erally sufficient  in  recent  exudation  without  medication. 


2IO  DISEASES    OF  THE   HEART   AND   LUNGS. 

Case  ist. — Rev. 34    years   old,   born   in   New 

Jersey  ;  father  died  at  the  age  of  54  of  phthisis  ;  family 
history  otherwise  good.  During  the  great  heat  of  last 
summer  ministerial  duties  were  heavy,  was  depressed 
about  business  affairs,  and  began  to  be  ill.  After  feel- 
ing weak  and  ''out  of  sorts  "  for  some  time,  was  taken 
with  hasmoptysis  on  the  morning  of  July  13,  1878. 
Became  apprehensive,  sleepless,  could  eat,  but  had  no 
appetite;  fell,  in  weight  from  122  to  117  pounds. 
Hawked  up  mucus,  but  had  no  cough  proper.  When 
lying  down  could  hear  whirring  noises  in  chest.  Had 
stitches  mostly  in  left  side  about  the  heart,  with  palpi- 
tation. Physical  examination  discovered  a  few  distinct 
rales  over  right  lung ;  left  side  a  few  rales  at  upper 
part,  but  in  the  lower  part  an  abundance  of  fine,  sub- 
crepitant  rales  back  and  front.  Respiration  feeble; 
could  not  fill  the  chest  fully  in  inspiration  ;  no  dulness, 
but  a  little  flatness  under  percussion  in  lower  part  of 
left  side. 

Diagnosis.  —  Plastic  exudation  within  the  pleurae, 
mostly  in  the  lower  part  of  the  left.  Directed  system- 
atic  expansion  of  chest  in  open  air,  walking,  with  milk 
diet.  Took  no  medicine,  except  cod-liver  oil ;  rubbed 
down  with  English  glove  night  and  morning. 

Re-examined  Nov.  7,  1878.  Respiration  and  expan- 
sion improved,  but  rales  remain. 

Re-examined  March  i,  1879.  ^^  signs  of  exudation 
have  disappeared.  Allowed  to  return  to  his  ministe- 
rial duties.  Weight,  130  pounds.  Eats  well;  sleeps 
well,  unless  excited,  and  feels  well.  Walks  five  or  six 
miles  every  afternoon,  in  addition  to  out-door  exercise 
in  the  morning;  has  walked  ten  or  twelve  miles  in  a 
day  without  over-fatigue.  Chest  was  measured  on  the 
i6th  of  November  last,  and  again  first  of  April ;  under 
the  arms  and  under  nipple.     Gained  under  the  arms, 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.   211 

after  exhausting-  the  lungs  half  an  inch,  in  ordinary  res- 
piration three  fourths  of  an  inch,  and  one  inch  and  one 
fourth  after  full  inspiration.  Under  nipple  gained  half 
an  inch  in  forced  expiration,  one  and  three  fourths 
inches  in  ordinary  respiration  and  two  inches  in  full 
inspiration. 

With  mild  medication  the  time  of  recovery  may  be 
shortened,  and  its  use  is  advisible  if  there  is  doubt 
about  the  organization  of  the  exudation. 

Case  3. — D.  E.  returned  from  Florida  in  the  spring 
of  1878.  Took  cold  about  two  months  before  leaving 
the  South  ;  continued  to  cough,  rapidly  lost  weight, 
from  180  to  160  lbs.;  had  two  attacks  of  hasmoptysis. 
Physical  examination  discovered  subcrepitous  rales 
right  side  posteriorly  ;  appetite  poor ;  dyspnoea  on  ex- 
ertion. Advised  to  go  to  Harper's  Ferry,  Va.,  and 
commence  walking  eight  to  fifteen  miles  each  day,  sys- 
tematically expanding  the  chest,  and  living  on  milk 
diet,  and  in  addition  to  take  a  cold  infusion  of  wild 
cherry  bark  with  chloride  of  ammonium — two  ounces 
of  the  bark  and  one  of  ammonium  in  two  pints  of  cold 
water  ;  tablespoonful  about  every  hour.  This  was  done 
strictly,  and  he  returned  in  about  three  weeks.  All 
signs  of  plastic  exudation  had  disappeared ;  had  re- 
gained the  weight  he  had  lost;  had  no  cough,  no 
dyspnoea  in  exercise,  and  has  remained  well  since. 

But  should  the  system  be  in  no  condition  to  respond 
to  those  simple  measures,  or  if  the  organization  of  the 
exudation  has  resulted  in  firm  adhesions  of  the  pleurae, 
with  commencing  consolidation  of  the  lung,  and  the 
simple  means  fail,  it  may  be  necessary  to  resort  to  posi- 
tive medication  by  mercurials- — calomel  and  Dover's 
powder  in  small  doses  until  the  teeth  are  tender,  which 
may  be  followed  by  bichloride  of  mercury  in  Huxham's 
tincture  of  bark  in  small  doses,  and  may  be  continued 


212  DISEASES   OF  THE   HEART   AND   LUNGS. 

for  months  in  addition  to  the  chloride  of  ammonium, 
and  systematic  expansion  of  the  chest  in  the  open  air, 
milk  diet,  etc. 

Case.  3. — A.  R.,  native  of  Scotland,  39  years  of  age, 
clerk.  Family  history  good.  Weight  in  health,  165 
lbs.  Began  to  be  ill  in  1874.  Frequently  took  colds; 
had  "  catarrh,"  but  kept  at  business ;  gradually  grew 
worse.  In  1875  had  some  inflammation  of  the  chest, 
which  was  checked ;  had  severe  coughing  spells,  with 
loss  of  strength  and  short  breath  ;  all  symptoms  grow- 
ing gradually  worse  until  October,  1878,  when  he  came 
to  be  examined. 

Pulse  frequent  and  irritable  ;  breathing  hurried  ;  con- 
stant coughing  ;  expectorating  yellowish  thick  mucus ; 
appetite  poor;  disturbed  sleep;  weighed  130  lbs. 

Physical  examination. — Almost  no  expansion  in  right 
side ;  restricted  on  left ;  dulness  over  right  lung,  espe- 
cially over  middle  portion  ;  not  so  great  over  left ;  fine 
dry  rales  over  right  side,  especially  over  middle  por- 
tion ;  some  crackling  rales  at  summit  of  right  lung ; 
softer  tearing  rales  over  left  side. 

Diagnosis. — Extensive  adhesions  in  both  pleurae ;  old 
and  organized  in  the  right,  with  consolidation  of  middle 
portion  of  lung  ;  fibroid  phthisis,  second  stage. 

Placed  him  at  once  on  calomel  and  Dover's  powder, 
to  make  the  teeth  sore  ;  then  to  follow  with  chloride  of 
ammonium  and  wild  cherry  bark,  cold  infusion,  and  fre- 
quent small  blisters  ;  systematic  expansion  of  the  chest  in 
the  open  air,  freedom  from  business,  milk  diet,  etc.  The 
mercurial  treatment  was  resumed  three  times,  and  car- 
ried to  the  point  of  mercurialization,  followed  by  blis- 
ters, etc.,  with  marked  improvement  of  rational  and 
physical  signs ;  chloride  of  ammonium  and  wild  cherry 
bark,  with  bichloride  of  mercury,  one  thirty  second  of 


NEW   CLASSIFICATION   OF   PHTHISIS   PULMONALIS.  21^ 

a  grain  three  times  daily  in  a  compound  tincture  of 
Peruvian  bark  were  continued  afterwards. 

He  was  permitted  to  return  to  his  business  in  January. 

Re-examined  April  22,  1879. —  -H^^^  gained  twenty 
pounds  in  weight  since  October  last.  Has  no  cough ; 
pulse  natural ;  respiration  quiet ;  temperature,  37°  C, 
(98.6  F.). 

Physical  examination  shows  increased  expansion  o£ 
chest ;  no  dulness ;  a  little  flatness ;  some  thickened' 
pleurae  still  remains  over  middle  portion  of  right  lung* 
behind ;  no  rales  on  either  side. 

Has  not  regained  full  strength,  although  very  much 
improved  ;  a  little  short  breathed  on  severe  exertion ; 
eats  well,  sleeps  well,  and  feels  perfectly  well  when  not 
over  exercising, 

When  the  fibroid  is  extensive  both  in  the  pleuras 
and  in  the  lung,  as  in  the  above  case,  mercurialization 
to  the  point  of  salivation  may  be  absolutely  necessary 
to  relieve  the  patient.  The  result  in  case  3  was  excep- 
tionally favorable,  and  cannot  be  regarded  as  the  rule 
for  all  cases  of  fibroid  in  the  second  stage.  Yet  to  save 
one  such  case  from  among  a  number  is  very  encourag- 
ing. The  careful  physician,  who  knows  how  to  use  his 
tools,  will  have  no  fear  of  doing  injury.  He  will  carry 
the  use  of  this  powerful  remedy  just  so  far  as  is  neces- 
sary to  accomplish  the  desired  end,  and  no  further. 
The  blister  will  be  most  efficient  when  the  system  is 
under  the  influence  of  the  mercurial. 

Systematic  expansion  of  the  chest  must  not  for  one 
moment  be  lost  sight  of,  no  matter  what  form  of  medi- 
cation may  be  adopted.  Indeed  it  should  be  considered 
that  all  medication  is  auxiliary  to  expansion-^to  make 
expansion  possible. 

Gently  fiUing  the  lungs,  holding  the  breath,  depend- 
ing upon  the  rarefaction  of  the  cool,  inspired  air  after 


214  DISEASES   OF  The   heart  and   LtTNGS. 

mixing  with  the  heated,  residual  air,  to  dilate  the  lungs' 
and  gain  expansion  of  the  chest.  When  there  is  no 
irritation  of  the  lungs  or  pleurae  the  air  may  be  forced 
into  the  lungs  and  held  as  long  as  possible,  that  con- 
tracting adhesions  may  be  overcome. 

Accurate  measurements  of  the  chest  should  be  made 
and  recorded  at  intervals,  that  progress  may  be  ascer- 
tained and  patient  encouraged.  Perhaps  no  simple 
method  of  gradual  expansion  is  more  effectual  than  rid- 
ing on  a  fast  walking  horse.  The  instinctive  balancing 
of  one's  self  on  the  horse  in  the  rolling  motion  of  fast 
walking  keeps  the  chest  expanded,  and  systematically 
exercises  all  the  muscles  of  the  body  without  fatigue. 
In  forcible  expansion  care  must  be  taken  not  to  do 
harm.  Adhesions  must  not  be  violently  torn  nor  put 
upon  the  stretch,  or  the  result  may  be  extension  of  in- 
flammatory action  and  further  disability  by  new  exuda- 
tion. The  pleura  has  been  torn  from  the  lung  by  the 
accident  of  falling,  and  death  has  resulted  from  hem- 
orrhage resembling  pulmonary  apoplexy. 

In  connection  with  systematic  expansion  the  subject 
of  climate  is  important,  as  expansion  in  pure  air  is  more 
beneficial  than  in  bad  air.  Change  of  scene  and  of  ac- 
customed thought  is  desirable,  also  out-door  exercise 
■and  cheerful  amusement  with  a  congenial  friend  in  a 
cool  equable  climate  free  from  malaria,  in  balsamic 
forests.  But  even  then  change  should  be  had.  The 
patient  does  best  who  goes  from  place  to  place.  The 
influence  of  change  upon  the  digestive  organs  is  a  mat- 
ter of  common  observation.  Sea  voyages  for  those  liv- 
ing inland,  to  the  mountains  for  those  living  by  the 
sea,  even  from  a  good  to  a  poor  climate  may  give  a 
temporary  benefit.  I  have  known  patients  to  improve 
rapidly  by  coming  from  healthy  hill  countries  to  New 


NEW   CLASSIFICATION   OF  PHTHISIS   PULMONALIS.   21^ 

York,  which  certainly  cannot  boast  of  perfect  climate 
for  a  phthisis  patient. 

Any  one  locality,  however  good,  should  not  be  re- 
commended for  all.  One  whose  taste  runs  in  that 
direction  will  do  best  where  there  is  hardship  and 
roughing  it,  with  plenty  of  incident,  while  others,  and 
especially  women,  may  do  better  in  congenial  society, 
surrounded  by  the  elegancies  and  comforts  of  fashion- 
able life. 

We  have  on  our  continent  every  variety  of  climate 
and  scene,  California,  Colorado,  Minnesota,  Canada, 
Texas,  Florida,  North  and  South  Carolina,  Georgia 
and  Virginia,  or  the  Adirondacks.  Short  voyages  also 
bring  us  to  the  Bermudas  and  West  India  Islands. 

But  if  there  is  progression  in  fibrination,  the  time  may 
come  when  the  patient  must  desist  from  exercise,  and 
keep  his  room  or  even  his  bed  for  a  lengthened  period, 
using  the  gentlest  means  to  keep  the  chest  expanded, 
living  upon  the  most  nutritious  and  stimulating  food* 
Using  rectal  alimentation  with  defibrinated  blood,  intel- 
ligent mercurialization, •blistering,  and  tonics  to  cause 
re-absorption  of  newly  exuded  matter  which  may  so 
free  the  lungs  again  that  out-door  .gentle  exercise  may 
be  resumed  when  summer  has  set  in.  From  the  latter 
part  of  February  until  the  first  week  in  June  a  phthisis 
patient  who  cannot  seek  a  better  climate  should  keep 
his  room  by  a  cheerful  fire,  and  take  only  such  exercise 
as  he  can  indoors. 

Second  Division  of  Fibroidy  or  Second  Class.  Tuber- 
culated  fibroid  Phthisis, 

To  this  division  belong  the  great  majority  of  the  cases 
of  phthisis  which  come  under  our  observation,  too  late 
for  curative  treatment. 

The  disease  is  essentially  fibroid  ;  the  tubercular  ele- 
ment is  a  complication,  and  is  accidental.      Niemeyer 


2l6  DISEASES   OF   THE   HEART  AND   LUNGS. 

says  that  the  fear  in  a  case  of  catarrhal  pneumonia  is 
that  it  may  become  tubercular.  Substituting  fibroid 
for  catarrhal  pneumonia,  I  would  entirely  agree  with 
his  anxiety  in  regard  to  this  complication.  The  low- 
ered vital  power  in  a  fibroid  lung  or  pleura,  with  the 
constant  irritation  caused  by  the  interplural  adhesions, 
invite  the  exudation  of  tubercle.  A  scrofulous  diathe- 
sis with  fibroid  lung  is  almost  certain  to  become  tuber- 
culated,  and  it  is  this  fact  which  makes  it  so  necessary 
to  watch  and  to  remove  the  first  beginnings  of  the 
fibroid  condition. 

The  causes,  history,  physical  signs  and  treatment  of 
this  division  up  the  time  of  tuberculation  have  already 
been  glanced  at  in  the  consideration  of  the  first  division 
of  the  fibroid  class.  The  new  physical  signs  denoting 
the  advent  of  tuberculation  will  need  to  be  watched 
for  with  great  assiduity,  for  upon  their  appearance  or 
non-appearance  depends  very  largely  the  hope  or  des- 
pair which  will  govern  the  efforts  for  cure  or  for  palli- 
ation. 

These  signs  are  areas  of  duhiess  which  raised  pitch 
under  percussion,  with  loss  of  true  respiratory  murmur, 
followed  by  bronchial  breathing,  bronchophony,  raised 
temperature,  hurried  pulse,  and  respiration.  Decided 
exacerbations,  chill,  fever  and  sweating,  periodically 
returning.  The  cold  sweat  coming  on  after  midnight 
is  like  the  approach  of  death,  and  is  horrible  to  the 
patient. 

When  the  tubercular  masses  soften  and  open  into  a 
bronchus,  the  characteristic  expectoration  may  an- 
nounce the  formation  of  a  cavity,  or  the  expectoration 
may  not  be  observed.  A  general  amelioration  of  all  the 
symptoms  may  occur  at  this  period.  The  chills  and 
fever  may  subside,  the  pulse  and  temperature  may  fall 
to  normal,  the  respiration  become  slower  and  fuller, 


NEW    CLASSIFICATION   OF   PHTHISIS    PULMONALIS.    21^ 

the  hectic  and  night  sweat  disappear.  Perhaps  the 
patient  begins  to  eat  and  sleep  well,  and  from  this  time 
forward  there  may  be  continuous  improvement. 

Great  injustice  may  happen  to  the  attendant  phy- 
sician should  he  be  changed  for  another  a  short  time 
before  the  formation  of  a  cavity,  for  the  great  improve- 
ment of  all  the  symptoms  will  naturally  be  attributed 
to  the  new  doctor.  Many  patent  medicines  have  gained 
great  popularity  from  having  been  '*  tried''  in  the  right 
time.  But,  unfortunately  for  the  patient,  such  com- 
plete rehef  is  not  always  obtained.  Other  tubercula- 
tions  may  also  be  going  through  the  same  process  of 
softening,  and  the  amelioration  may  be  but  partial  and 
only  for  a  short  time. 

The  physical  signs  of  a  cavity  are  made  exceedingly 
plain  by  the  good  sound-conductirg  quality  of  fibroid 
lung  and  adherent  pleurae.  The  cavernous  or  amphoric 
respiration,  and  the  reverberations  or  echoes  of  rales 
and  gurgles  in  the  cavities  with  pectoriloquy,  vocal  and 
whispering,  leave  no  doubt  of  what  has  taken  place. 

Auscultation  may  discover  remaining  concretions 
which  may  soften  in  time  and  repeat  the  same  signs 
and  symptoms  until  they  also  are  discharged. 

The  condition  of  cavities  may  be  studied  for  the  bene- 
fit of  the  patient:  As  to  whether  they  are  empty  or 
filled  or  partly  filled  with  fluid.  Also  as  to  the  manner 
of  their  opening  into  a  bronchus,  from  the  walls  of  the 
cavity  or  from  the  roof  or  from  the  floor.  Should  the 
opening  be  from  the  bottom  of  the  cavity,  it  will 
always  be  empty  when  the  patient  is  in  an  upright 
position.  Should  it  be  from  the  top  of  the  cavity  it 
may  be  overlooked  during  examinations  made  in  the 
middle  of  the  day,  the  usual  time  of  visits,  but  may  be 
readily  discovered  early  in  the  morning,  or  after  the 
patient   has   retired   in   the   evening,  times   when   the 


2l8  DISEASES   OF  THE   HEART  AND   LUNGS. 

cavity  will  be  partly  empty  from  the  recumbency  of 
the  patient. 

A  knowledge  of  these  simple  facts,  gained  by  careful 
auscultation,  may  be  utilized  for  the  comfort  of  the  suf- 
ferer. 

Learning  the  manner  of  the  connection  with  a  bron- 
chus may  enable  us  to  relieve  distressing  night-cough 
without  the  use  of  opiates.  A  patient  may  sleep 
quietly  after  retiring,  for  some  hours,  and  then  be 
awakened  and  kept  awake  by  cough  the  rest  of  the 
night,  or  he  may  commence  coughing  the  moment  he 
lies  down  or  turns  upon  one  side,  and  he  instinctively 
seeks  the  position  which  gives  him  most  ease  from 
strangling  cough,  and  submits  to  a  constant  teasing 
cough  that  only  yields  to  large  doses  of  opium.  After 
examination,  teach  him  to  take  that  position  which  will 
soonest  empty  the  cavity  and  keep  it,  notwithstanding 
the  coughing,  until  the  cavity  is  thoroughly  emptied, 
then  he  can  take  his  usual  position  and  sleep  quietly 
until  morning. 

These  practical  facts  were  embodied  in  a  paper  pre- 
pared for  the  Academy  of  Medicine,  by  the  late  Dr. 
Geo.  P.  Cammann,  and  which  I  had  the  honor  of  read- 
ing before  the  Academy  after  the  writer's  death. 

Cavities  in  the  lungs  are  not  always  of  a  tuberculous 
origin.  A  portion  of  lung  tissue  may  necrose  from 
strangulation  by  contracting  fibroid  and  become  gan- 
grenous, and  a  cavity  result  which  may  remain  open, 
or  even  enlarge  by  wasting  from  its  walls,  or  it  may  be 
of  traumatic  origin.  I  have  known  one  to  occur  from 
tapping  with  a  trocar  into  a  lung  bound  to  the  chest- 
walls  by  adhesions.  A  ball  of  lead  has  been  the  cause 
of  a  cavity  after  having  been  in  the  lung  for  many  years. 
From  whatever  cause,  a  cavity  in  the  lung  is  a  grave 
accident. 


NEW   CLASSIFICATION  OF  PHTHISIS   PULMONALIS.   219 

Dry  crackling  rales  from  old  pleuretic  adhesions  are 
loudly  echoed  in  a  cavity  near  the  surface  of  the  lung-, 
and  assist  in  differentiating  it  from  a  dilated  bronchus,  in 
which  they  are  much  feebler,  if  heard  at  all,  and  the 
sound  seems  to  escape,  while  in  a  cavity  they  are  de- 
fined and  echoed  from  the  walls. 

Cracked-pot  sound  is  also  easily  distinguished  when 
the  cavity  is  near  the  surface,  but  even  when  centric 
the  expert  ear  may  catch  the  peculiarity  of  the  double- 
echoed  quality  of  sound  with  that  of  the  sudden  expul- 
sion of  air  into  the  bronchus. 

Treatment  of  the  tuberculated  division  of  the  second 
class  must  be  a  judicious  combination  of  that  already 
given  for  fibroid  and  for  purely  tubercular,  with  the 
hope  of  delaying  progress,  if  not  arresting  it  alto- 
gether. 

The  earliest  signs  of  plastic  exudation  within  the 
pleurae  must  be  heeded  and  removed  is  the  lesson 
that  the  consideration  of  this  formidable  disease  im- 
presses upon  us,  but  if  the  fibroid  lung  has  be- 
come tuberculated,  there  must  be  a  double  endeavor 
to  prevent  the  extension  both  of  fibroid  and  of  the 
tubercular.  The  resort  to  mercurials  must  be  more 
sparingly  made  than  in  the  purely  fibroid,  and  yet  they 
must  not  be  wholly  disused.  The  bichloride  of  mer- 
cury, with  tonics,  will  be  the  principal  resort.  Chlo- 
ride of  ammonium  will  be  of  more  value  than  in  either 
the  pure  tubercular  or  fibroid  alone,  as  it  meets  the 
indications  in  both.  The  exercise  must  be  adapted  to 
the  conditions,  and  too  forcible  expansion  must  not  be 
made.  Milk  diet  in  large  quantities  must  be  encour- 
aged and  insisted  upon. 

Lord  Bacon  says,  in  effect,  that  many  believe  they 
cannot  take  milk  without  becoming  bilious,  because 
they  take  but  little  at  a  time,  which  coagulates,  but 


220  DISEASES   OF  THE   HEART  AND   LUNGS. 

that  if  they  take  large  draughts,  the  acid  is  diluted,  and 
digestion  will  take  place.  I  have  repeatedl}^  demon- 
strated the  truth  of  his  observation.  In  order  to  take 
large  quantities  of  milk,  it  is  necessary  to  proscribe 
other  kinds  of  animal  food.  Two  or  three  quarts  of 
good  milk  may  be  taken  daily  for  weeks,  even  by  a 
feeble  person.  The  stomach  must  be  educated  to  re- 
ceive this  quantity,  and  it  must  be  done  gradually.  In 
fibroid  phthisis  the  patients  are  apt  to  be  carnivorous, 
and  have  contracted  stomachs,  so  that  at  first  they  are 
unable  to  take  a  large  amount  of  food  at  one  time.  But 
system  and  perseverance  will  overcome  this  difficulty. 
By  the  constant  use  of  milk  the  stomach  dilates,  and 
the  blood-vessels  enlarge,  and  more  nutrition  is  carried 
to  the  capillaries,  and  weight  of  the  body  will  be  in- 
creased. 

The  increase  in  weight,  which  comes  to  drinkers  of 
large  quantities  of  any  liquid,  is  owing  to  this  acquired 
capacity  to  receive  nutrition.  Large  quantities  of  milk 
at  regular  intervals,  with  systematic  expansion  of  the 
chest,  stands  first  in  importance  in  treatment  of  all  forms 
of  fibroid  phthisis.  The  deposit  of  fat  in  the  system  is 
an  assurance  that  phthisis  is  held  in  abeyance.  Oc- 
casionally a  change  may  be  made,  and  a  mixed  diet 
of  more  stimulating  food  may  be  allowed,  to  continue 
only  for  a  short  time,  again  to  return  to  strict  milk  diet, 
until  health  is  restored. 

The  subject  of  tubercle  I  have  not  attempted  to  dis- 
cuss, and  the  same  may  be  said  of  minute  pathology 
and  histology,  except  in  a  clinical  and  practical  way, 
leaving  the  niceties  to  be  settled  by  those  who  are 
making  them  a  subject  of  particular  study. 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM.    221 


XT. 

Therapeutics  of  Chloride  of  Ammonium. 

Sal  ammoniac,  muriate  of  ammonia,  hydrochlorate 
of  ammonia,  or,  properly,  chloride  of  ammonium,  are 
the  designations  of  the  salt  some  of  the  remedial  powers 
of  which  I  propose  to  consider  in  this  paper. 

Our  pharmacopoeia  presents  us  with  a  variety  of 
medicinal  agents,  and  each  has  its  measure  of  power, 
each  acts  in  a  specific  way  peculiar  to  itself  or  its  class 
upon  the  living  organism,  and  is  beneficial,  or  other- 
wise, according  to  the  wisdom  of  the  practitioner  di- 
recting its  use. 

Our  knowledge  of  therapeutics  is  mostly  empirical ; 
a  priori  reasoning  has  little  to  do  in  determining  our 
choice  of  agents  ;  a  knowledge  of  their  intrinsic  value 
is  approached  only,  after  many  trials  by  different  observ- 
ers under  many  and  different  circumstances.  In  this 
view,  it  may  be  asserted  that  all  the  remedies  in  com- 
mon use  are  still  upon  trial.  In  endeavoring  to  esti- 
mate the  value  of  a  remedy  by  the  light  of  experience, 
in  order  to  prevent  hasty  conclusions,  it  is  well  enough 
to  premise  that  many  of  the  sick  calls  any  practitioner 
may  attend  are  either  wholly  imaginary,  or  of  that 
class  of  diseases  called  functional,  in  which  the  "  medi- 
catrix  naturce'  is  frequently  competent  to  perform  a 
cure,  especially  when  stimulated  by  the  imagination  ; 
but  that  when  a  material,  potent  substance  is  requisite 
to  remove  a  morbific  cause,  or  impress  a  vital  change 
upon  the  system,  the  domain  of  fancy  ends,  and  that  of 
material  facts  takes  its  place. 


222  DISEASES   OF  THE   HEART  AND   LUNGS. 

The  idea  that  all  medicines  are  still  and  ever  must  be 
on  trial  till  we  have  arrived  at  perfection  in  our  knowl- 
edge of  therapeutics  is  illustrated  in  opium.  How 
long  has  the  poppy  been  the  sweet  soother  of  pain  and 
care,  giving  balmy  sleep  to  the  wearied,  excited  brain, 
and  rest  to  the  tired  limbs;  when  fever  rages,  and 
every  fibre  of  the  body  is  quick  with  anguish,  how 
blessed  is  the  repose  it  gives,  how  delightful  the  forget- 
fulness  it  brings !  and  yet  it  is  but  yesterday  that  one 
among  us  taught  us  its  power  in  arresting  certain  forms 
of  inflammation.  Opium,  one  of  the  oldest  medicines  in 
use,  is  still  on  trial.  Clark,  even  now,  superintends  its 
use  at  Bellevue,  and  shows  the  young  physician  that 
with  it  he  can  reduce  the  respirations  to  seven,  and 
even  to  five,  in  a  minute,  and  thus  hold  back  the  dart  of 
the  destroyer  till  the  inherent  power  of  nature  comes 
in  to  assist  in  the  restoration  of  the  patient  to  her  family 
and  friends.  Possibly,  we  do  not  even  yet  know  all 
about  opium. 

The  use  of  ammonia  as  a  remedy  may  be  as  ancient 
as  that  of  opium,  but  of  that  we  are  not  assured,  for,  ac- 
cording to  Stille's  Therapeutics,  *'The  sal  ammoniac  of 
the  ancients  is  supposed  to  have  been  rock  salt,  and  to 
have  derived  its  name  from  the  circumstance  of  its 
being  procured  near  the  temple  of  Jupiter  Ammon  of 
Lybia. 

"  The  temple  itself  was  called  after  the  province  Am- 
monia, in  which  it  was  situated,  a  name  which  signifies 
sandy.  In  the  middle  ages  muriate  of  ammonia  was 
known  as  sal  armoiacum,  or  Armenian  Salts,  in  refer- 
ence to  one  of  its  commercial  sources.  The  Arabian 
physicians  speak  of  its  preparation  from  the  soot  made 
by  burning  (camel's)  dung  ;  of  its  application  to  the  eye 
for  the  removal  of  leucoma;  of  its  use  to  cure  relaxa- 
tion of  the  palate,  and  of  its  power  of  determining  the 


THERAPEUTICS   OF   CHLORIDE   OF  AMMONIUM.    223 

humors  to  the  surface  of  the  body.  They  also  refer  to 
its  being-  mixed  in  a  liniment  of  oil  and  vinegar,  for 
the  cure  of  itch.  In  modern  times  there  is  but  little 
recorded  of  its  use  as  a  medicine  until  the  last  century, 
when  it  became  a  favorite  remedy  with  German  physi- 
cians, and  continues  to  be  regarded  by  them  as  in  many 
cases  a  profitable  substitute  for  mercury,  antimony,  or 
iodine." 

In  the  fall  of  185 1  my  attention  was  drawn  to  the  use 
of  muriate  of  ammonia  by  reading  in  Watson's  Practice 
of  Medicine  an  account  of  his  use  of  this  salt  in  a  cer- 
tain form  of  face-ache  which  he  distinguishes  from  neu- 
ralgia and  tic  douloureux,  and  then  says:  "  I  allude  to 
this  for  the  sake  of  saying  that  some  years  ago  I  was  in- 
structed by  an  experienced  old  apothecary  that  this  face- 
ache  might  be  almost  always  and  speedily  cured  by  the 
muriate  of  ammonia ;  a  medicine  that  is  seldom  given 
internally  here,  although  it  is  so  much  used  in  Germany ; 
and  I  have  again  and  again  availed  myself  of  this  hint 
and  been  much  thanked  by  my  patients  for  the  good  I 
did  them  with  this  muriate  of  ammonia."  Dr.  Watson 
gave  it  in  half-drachm  doses  three  or  four  times  daily  in 
solution.  As  my  object  in  this  paper  is  to  bring  this 
practical  subject  before  the  profession  in  a  strong  light, 
and  give  all  the  information  I  possess  of  the  curative 
power  of  this  valuable  remedy,  I  do  not  know  that  I 
can  do  so  more  readily  than  by  putting  my  own  experi- 
ence in  the  form  of  a  narrative. 

I  had  just  been  appointed  visiting  physician  to  the 
Northern  Dispensary,  and  I  had  abundant  opportunity 
of  testing  the  muriate  of  ammonia,  not  only  in  the  face- 
ache  described  by  Dr.  Watson,  but  also  in  other  forms 
of  neuralgia,  even  when  of  malarial  origin.  In  most 
cases  I  was  delighted  with  the  speedy  relief  it  afforded. 
I  was  myself  a  martyr  to  the  form  of  hemicrania  called 


224  DISEASES   OF   THE   HEART  AND   LUNGS. 

migrain,  and  frequently  have  been  obliged  to  leave  my 
work  on  account  of  it,  and  go  home  and  take  one  or  two 
doses  of  half  a  drachm  each  at  an  interval  of  half  an 
hour,  after  which  I  was  generally  able  to  resume  my 
duties.  I  had  during  that  fall  a  number  of  typhus  fever 
patients,  and  I  noticed  that  many  of  them,  on  the  second 
or  third  day  after  taking  to  bed,  became  unconcious 
and  had  low  muttering  delirium,  etc.,  the  usual  symp- 
toms of  ship  fever.  It  occured  to  me  that  the  muriate 
of  ammonia  might  relieve  these  symptoms ;  I  used  it 
it  and  I  believe  with  salutary  effect ;  it  would  fre- 
quently arouse  them  to  consciousness.  I  gave  ten 
grains  in  solution  every  half  hour  with  beef  tea  and 
brandy,  till  the  patient  would  awake  and  be  able  to 
answer  questions.  I  believed  also  that  those  treated 
with  the  ammonia  were  less  liable  to  inflammatory  com- 
plications, and  that  it  had  a  permanent  and  happy  effect 
till  convalescence  was  established.  This  experience 
seemed  to  me  to  prove  that  this  agent  had  a  power  not 
generally  known,  and  that  it  must  act  on  general  prin- 
ciples, and  I  determined  to  test  it  in  other  and  different 
cases.  During  the  following  winter  there  was  an  epi- 
demic of  scarlatina  throughout  my  district,  of  a  mild 
tvpe,  which  I  treated,  as  my  predecessor  had  done  be- 
fore me,  with  chlorate  of  potash  and  anointing  the  body 
with  lard.  The  success  was  remarkable,  for  out  of 
more  than  170  cases  I  reported  but  three  deaths.  It 
seemed  to  me  then  that  this  was  nearly  a  perfect  treat- 
ment for  this  usually  dreadful  disease,  but  the  following 
year  there  was  another  epidemic  of  more  limited  extent, 
but  the  mortality  was  frightful.  In  my  despair  I  sought 
other  remedies,  and  it  occurred  to  me  to  add  muriate 
of  ammonia  to  the  chlorate  of  potash,  and  the  result 
was  eminently  satisfactory,  for' the  disease  was  cer- 
tainly more  under  control  with  this  combination  than 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM.     225 

with  the  chlorate  of  potash  alone,  especially  when  the 
treatment  was  commenced  early,  in  the  anginous  form  ; 
the  enlargement  of  the  glands  and  tumefaction  of  the 
neck  were  less,  and  there  was  less  tendency  to  deep 
ulceration  in  the  throat.  Its  effect  in  neuralgia  about 
the  head,  and  also  its  effect  in  typhus  fever,  determined 
me  that  if  sunstroke  or  insolation  should  come  again 
under  my  care,  I  would  use  with  hope  for  relief  muri- 
ate of  ammonia.  During  the  summer  of  1852  a  num- 
ber of  cases  of  sun-stroke  occured  in  my  practice,  and 
I  treated  them  with  this  salt,  in  solution,  in  ten  grain 
doses  every  fifteen  minutes.  The  result  was  happier 
than  I  had  dared  to  anticipate ;  all  the  cases  treated 
with  the  ammonia,  thoroughly  and  promptly,  when  not 
actually  moribund,  speedily  recovered.  Many  of  my 
medical  friends  also  used  the  muriate  of  ammonia  in 
insolation  with  happy  effect.  1  furnished  a  very  imper- 
fect account  of  the  cases  which  I  treated  during  that 
and  the  following  year  which  was  published  in  the 
N.    Y.  Journal  of  Medicine  for  1854. 

Having,  in  the  foregoing  experiments,  satisfied  my- 
self of  the  power  of  muriate  of  ammonia  to  effect  vital 
changes  in  the  human  system  when  under  the  influence 
of  disease,  I  conjectured  that  it  must  be  by  rapid  ab- 
sorption into  the  blood,  and  thus  by  being  carried  into 
every  part  of  the  body,  and  by  being  brought  into  con- 
tact with  the  capillary  nerves,  it,  in  some  unexplained 
way,  changed  the  altered  condition  of  the  blood,  and 
at  the  same  time  controlled  the  circulation.  In  ex- 
plaining these  views  to  my  associates  at  the  Northern 
Dispensary,  I  stated  that  should  Asiatic  cholera  come 
again  into  my  hands  I  should  expect  happy  effects  from 
the  use  of  the  combination  of  muriate  of  ammonia  and 
chlorate  of  potash.  It  was  not  long  before  an  opportu- 
nity was  afforded  me.     On  the  23d  of  May,  1854,  I  was 


226  DISEASES   OF  THE   HEART   AND    LUNGS. 

called  to  see  an  Irish  emigrant  who  had  landed  the 
evening  before,  and  was  then  staying  with  friends  liv- 
ing in  the  rear  of  86  Seventh  Avenue.  He  had  cold 
tongue,  sunken  eyes,  sodden  fingers,  with  frequent  dis- 
charges from  the  bowels,  which  his  attendants  told  me 
were  bloody,  and  they  said  he  had  dysentery.  I  was 
unable  to  make  a  clear  diagnosis  at  the  time,  but  pre- 
scribed calomel  and  opium  and  made  an  appointment 
to  call  again  next  day ;  but  the  family  becoming  fright- 
ened took  him  to  hospital,  and  he  died  on  the  way 
thither.  On  the  25th  of  May  I  was  called  to  the  same 
family  to  see  a  little  girl  ten  years  old,  and  found  her  in 
collapse.  Mustard  was  applied  externally,  and  stimu- 
lants were  attempted  to  be  given  by  the  mouth,  but  she 
died  a  couple  of  hours  afterwards.  The  following 
day  I  was  called  to  see  the  mother  of  the  child  and 
found  her  exhibiting  the  usual  signs  of  cholera.  I  hesi- 
tated to  give  her  the  mixture  of  muriate  of  ammonia 
and  chlorate  of  potash,  and  prescribed,  instead,  acetate 
of  lead  and  opium.  She  died  the  next  day.  I  now  re- 
solved that  the  next  case  should  have  the  benefit  of  the 
mixture  of  the  chlorates,  In  a  few  days  I  was  called  to 
gee  9,  German  emigrant  on  the  corner  of  Tenth  Ave- 
jiue  and  Twenty-first  Street,  and  found  him  in  a  back 
basement,  badly  lighted  and  without  ventilation.  He 
was  in  collapse,  was  vomiting  frequently,  and  had  rice 
water  discharges  from  the  bowels.  I  prescribed  the 
following  mixture  :  R. — Ammon.  murias.,  drams  2  ; 
potass,  chloras.,  dram  i  ;  aqua  camph.,  oz.  4;  spts.  eth. 
nit;  tr.  opii  camph.  aa.,  oz.  i.  S. — Tablespoonful 
every  half  hour. 

When  I  visited  him  in  the  evening  of  the  same  day 
the  vomiting  had  ceased,  there  was  sensible  reaction, 
but  he  still  had  occasional  passages  from  the  bowels. 
The  next  morning  he  was  convalescent     After  this  I 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM.    22/ 

steadil}^  used  this  mixture  in  cholera  with  gratifying" 
success.  Some  of  the  gentlemen  connected  with  me  at 
the  Northern  Dispensary  also  used  it  and  were  pleased 
with  its  effects.  It  evidently  stimulated  the  secretions, 
especially  those  of  the  liver  and  kidneys,  and  its  effect 
on  the  circulation  in  collapse  was  notable.  The  late  Dr. 
Cammann  told  me  that  he  was  called  up  in  the  night, 
that  summer,  to  see  one  of  his  neighbors  in  Fourteenth 
Street,  in  consultation  with  the  attending  physician. 
The  patient  was  in  collapse  and  was  sinking.  Dr. 
Cammann  advised  the  mixture  of  muriate  of  ammonia 
and  chlorate  of  potash.  The  pulse  was  absent  below 
the  bend  of  the  elbow,  but  after  taking  a  dose  of  the 
mixture  it  could  be  felt  creeping  again  down  the  artery 
to  the  wrist,  when  after  a  little  while  it  would  again  dis- 
appear. This  fact  was  noticed  by  both  physicians  for 
an  hour  or  two,  but  in  the  end  the  medicine  ceased  to 
have  its  effect,  and  the  patient  died.  In  many  of  the 
successful  cases  under  my  care  it  was  the  only  medi- 
cine given,  whilst  in  others  it  would  be  instantly  reject- 
ed from  the  stomach,  and  persistence  in  its  use  had 
but  little  effect  till  after  the  exhibition  of  a  full  dose  of 
calomel,  when  the  mixture  would  be  retained,  and  as 
far  as  I  know  there  were  no  bad  results  from  the  use 
of  the  two  remedies  at  the  same  time. 

About  this  time  I  learned  from  my  friend  Dr.  G.  C. 
E.  Weber  of  the  use  of  muriate  of  ammonia  among 
German  physicians  in  bronchitis  and  throat  affections, 
and  I  began  its  trial  in  treating  these  diseases  in  combi- 
nation with  chlorate  of  potash,  and  was  pleased  with 
the  result.  In  croup  I  had  been  in  the  habit  of  using 
large  doses  of  calomel  according  to  the  method  of  Dr, 
Bay,  of  Albany.  In  many  cases  it  was  speedily  success- 
ful in  arresting  the  disease,  in  others  a  larger  amount  of 
mercurial  had  to  be  given,  and  in  one  case,  at  least, 


228  DISEASES   OF  THE   HEART   AND   LUNGS. 

where,  although  the  croup  yielded,  consequences  fol- 
lowed that  caused  me  to  hesitate  in  repeating  the  treat- 
ment, and  subsequently  I  tried  the  mixture  of  ammonia 
and  chlorate  of  potash  instead,  and  I  Avas  surprised  as 
well  as  delighted  to  find  its  power  as  an  antiphlogis- 
tic and  defibrinating  agent  quite  as  manifest  as  that 
of  calomel  without  any  of  its  danger. 

In  two  years  I  noted  twelve  cases  of  croup  in  dispen- 
sary and  private  practice  treated  with  the  mixture  with 
but  one  fatal  result.  In  all  of  these  there  were  inflam- 
matory symptoms,  and  I  considered  them  all  to  be  true 
croup,  although  I  had  the  positive  evidence  of  seeing 
membrane  in  but  two  or  three  instances ;  still  there  was 
a  marked  difference  between  these  and  false  croup. 

A  little  girl,  five  years  of  age,  the  daughter  of  one  of 
my  neighbors,  had  been  suffering  with  hoarse  cough 
two  or  three  days,  and  was  given  domestic  remedies,  as 
it  was  considered  only  a  cold,  but  at  four  o'clock  in 
the  morning  she  became  so  much  oppresed  with  croupy 
cough  and  breathing  that  her  father,  becoming  alarmed, 
called  me  up.  The  cough  and  breathing  were  charac- 
teristic of  croup,  the  skin  was  hot  and  dry,  the  pulse 
full  and  frequent,  the  fauces  were  reddened,  but  there 
was  no  appearance  of  membrane.  I  sent  for  the  fol- 
lowing mixture :  R.  ammonias  muriat.,  drs.  3  ;  potass, 
chlorat,  dr.  i ;  aqua-cinnamon,  oz.  2 ;  syr.  g.  acaciae  oz. 
2 ;  syr.  senegae,  oz.  i ;  and  gave  her  a  teaspoonful  every 
five  minutes,  staying  with  her  until  she  had  taken  it  a 
number  of  times  ;  then,  instructing  the  father  to  con- 
tinue it  in  the  same  way  until  there  should  be  either  evi- 
dent relief  or  vomiting,  I  went  home.  At  eight  o'clock 
a.m.,  I  saw  her  again ;  the  cough  was  still  hoarse,  but 
was  accompanied  with  moist  rattles.  The  father  told 
me  he  had  continued  the  remedy  as  ordered  for  about 
two  hours,  when  there  was  coughing-  with  strangling, 


THERAPEUTICS   OF  CHLORIDE  OF  AMMONIUM.    22^ 

and  he  showed  me  the  basin  containing  the  ejected  mat- 
ter ;  floating  in  mucus  were  pieces  of  ragged  softened 
membrane,  one  of  them  about  two  arid  a  half  inches  long, 
and  a  little  more  than  half  an  inch  wide,  and  there  was 
also  what  appeared  to  be  the  detritus  of  membrane. 
She  had  croupy  cough  throughout  the  day,  and  the 
medicine  was  given  every  hour  or  two,  but  the  next 
day  she  was  fairly  cotivalescent.  I  cannot  doubt  that 
this  was  a  case  of  true  membranous  croup,  and  as  no 
other  medicine  was  used,  the  effect  of  the  mixture  as  a 
defibrinating  agent  was,  so  far,  positive  evidence.  Such 
happy  results  in  so  short  a  time  however,  are  the  ex- 
ceptions and  not  the  rule.  Usually  a  longer  continu- 
ance of  the  mixture  is  necessary  before  the  appearance 
of  loosened  membrane  is  manifested. 

Sometimes  in  croup,  as  in  cholera,  the  mixture  had 
no  other  effect  than  to  irritate  the  stomach  until  after 
a  large  dose  of  calomel  was  given. 

A  boy  twelve  years  old,  at  the  Protestant  Episcopal 
Orphans'  Home  and  Asylum,  was  noticed  to  be  croupy 
on  Wednesday,  and  was"  told  by  the  matron  to  take  the 
mixture,  which  is  always  kept  in  the  institution  ready 
for  use  ;  he  did  so  and  seemed  to  be  relieved.  On 
Thursday  evening  he  was  again  croupy,  and  was  again 
ordered  to  take  the  mixture  ;  being  old  enough  to  wait 
on  himself,  he  was  not  watched,  and  as  the  medicine  was 
very  disgusting  to  him,  he  took  it  sparingly.  On  Friday 
morning  all  the  croupy  signs  were  increased.  It  was  the 
day  for  the  ladies  to  meet  and  sew.  A  messenger  was 
sent  to  me,  but  in  the  meantime,  at  the  suggestion  of 
many  of  the  sympathizing  ladies,  he  was  given  jCoxe's 
hive  syrup,  and  syrup  of  ipecac  and  squills,  alternately 
till  when  I  arrived  his  stomach  would  keep  nothing  at 
all.  I  immediately  gave  him  a  large  dose  of  calomel,  after 
which  he  took  the  mixture  and  retained  it.     He  was  in 


230  DISEASES   OF  THE   HEART  AND   LUNGS, 

a  state  of  excitement  with  a  constant  cough  of  a  ring- 
ing,  brassy  character ;  breathing  was  difficult  and  he 
spoke  only  in  a  hoarse  whisper ;  the  fauces  were  red  but 
no  membrane  could  be  seen.  The  medicine  was  con< 
tinned  at  frequent  intervals  all  night,  and  on  Saturday 
morning  he  was  spitting  up  small  pieces  of  softened 
membrane ;  the  breathing  was  less  difficult  and  the 
cough  had  lost  its  brassy  character,  though  still  some- 
what croupy.  The  medicine  was  continued  through 
the  day  and  the  next  night,  but  at  longer  intervals,  and 
there  were  more  or  less  evidences  of  expectorated 
membrane,  till  Sunday  morning,  when  he  seemed  much 
better ;  the  croupy  cough  was  gone,  he  could  speak  in 
his  natural  voice  and  his  breathing  was  but  little  affected. 
The  medicine  was  discontinued  and  he  was  ordered 
nourishing  food  alone.  Still  the  boy  was  very  much 
depressed  in  spirits  and  expressed  his  beliei  that  he 
would  never  get  well.  About  two  o'clock  on  Monday 
morning  I  was  called  in  haste  and  found  him  with  livid 
lips  and  cold  extremities,  struggling  for  breath ;  while 
flapping  rattles  were  heard  over  the  chest;  still  his 
voice  was  not  gone.  He  died  in  about  an  hour  after  I 
arrived.  This  was  a  case  of  true  membranous  croup,  the 
mixture  of  muriate  of  ammonia  and  chlorate  of  potash 
had  but  little  effect  till  after  the  exhibition  of  the  calomel 
and  then  its  action  as  a  defibrinator  was  clearly  manifes- 
ted. On  Sunday  morning  the  larynx  and  upper  part  of 
the  trachea,  at  least,  were  cleared  of  membrane,  and  the 
fatal  onset  of  suffocative  dyspnoea  was  owing  to  occlu- 
sion of  the  smaller  bronchiae,  either  from  membrane  be- 
coming loosened  or  from  the  bronchia  being  closed 
with  tenacious  mucus.  I  could  mention  many  other 
cases  of  croup  treated  with  the  mixture  of  muriate  of 
ammonia  and  chlorate  of  potash,  all  showing  more  or 
less  power  of  the  remedy  to  relieve  the  little  sufferers. 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM,    23 J 

but  I  deerri  these  two  cases  sufficient  to  establish  its 
Value,  as  they  are  in  a  good  degree  a  type  of  the  others^ 

Iri  1859  diphtheria  made  its  appeafarice  in  New  Yorki 
I  had  diligently  tead  the  British  medical  journals^ 
noticing  the  many  communications  describing  the  dis- 
ease and  relating  the  effects  of  the  different  medicinal 
agents  used  iri  conlbatting  it ;  a  careful  study  of  these 
cases  had  produced  in  riiy  mind  the  conviction  that  the 
most  effectual  medicines  employed  were  the  chlorates 
in  some  form,  and  especially  the  chlorates  of  soda  and 
potash  with  the  muriated  tincture  of  iron.  Conse- 
quently I  was  prepared  to  use  what  my  experience 
leads  me  to  consider  by  far  the  most  effectual  combi- 
nation of  chlorates,  the  mixture  of  muriate  of  ammonia 
and  chlorate  of  potash. 

I  treated  the  first  cases  that  came  under  my  hands 
with  the  mixture  and  I  was  not  disappointed  in  the 
good  results  I  had  hoped  from  it.  I  sometimes  added 
to  the  mixture  muriated  tincture  of  iron,  and  sometimes 
gave  iron  and  quinine  in  another  form  separately,  always 
giving  stimulants  and  nourishment,  but  the  benefit  of 
the  mixture  was  notable,  and  occasionally  marvellously 
prompt  in  removing  membrane  from  the  fauces  in  a 
few  hours,  but  generally  about  two  days  of  medication 
was  required,  while  in  some  long  and  persistent  treat- 
ment was  necessary.  I  saw  it  both  in  private  and  dis- 
pensary practice,  and  it  appeared  as  an  epidemic  seve- 
ral times  at  the  Orphans'  Home.  I  varied  the  treat- 
ment myself  by  using  that  which  had  been  much 
praised  by  others,  and  watched  the  effect  of  other 
modes  of  treatment  in  the  hands  of  other  practitioners, 
but  I  have  not  yet  seen  any  one  form  of  medication 
that  in  my  estimation  filled  all  the  requisities  for  suc- 
cess so  well  as  the  mixture  of  ammonia  and  chlorate 
of  potash. 


232  DISEASES   OF  THE   HEART  AND   LUNGS. 

There  is  a  form  of  diphtheria  in  which  the  tendency  is 
for  the  membrane  to  extend  into  the  larynx  and  air 
passages,  and  has  been  termed,  I  think  properly,  diph- 
theritic croup.  When  the  membrane  appears  in  the 
air  passages  below  the  epiglottis  it  differs  in  no  way, 
so  far  as  I  know,  from  the  membrane  of  croup,  and  I 
consider  it  quite  consistent  with  the  existing  facts  that 
there  should  be  true  diphtheritic  membrane  above  the 
epiglottis  and  true  croup  membrane  below,  during  the 
same  attack.  No  one  who  has  seen  much  of  this  dis- 
ease need  be  told  that  when  in  a  case  of  diphtheria  the 
voice  becomes  hoarse  and  whispering,  the  breathing 
difficult,  and  the  cough  croupy,  that  the  case  is  one  of 
great  gravity,  for  these  signs  indicate  the  presence  of 
membrane  in  the  larynx ;  in  fact  they  are  the  signs  of 
membranous  croup. 

I  have  seen  cases  in  diphtheritic  croup,  as  in  true 
croup,  get  well  using  no  other  medicine  than  the  mix- 
ture of  muriate  of  ammonia  and  chlorate  of  potash,  but 
I  have  also  seen  others  die  under  the  most  persistent 
use  of  this  medicine. 

On  account  of  the  disease  being  diphtheria,  I  had  hesi- 
tated to  use  calomel  as  I  had  done  successfully  in  true 
croup,  but  a  number  of  unfortunate  cases  determined 
me  to  use  more  decided  measures ;  to  give  calomel  and 
tartarized  antimony  in  combination,  in  one  or  two  doses, 
and,  after  thus  forcing  an  entrance  into  the  system  to 
complete  the  treatment  with  the  muriate  of  ammonia  and 
the  chlorate  of  potash.  Such  a  case  occured  to  me  in 
January  last.  A  little  girl,  eleven  years  old,  had  sore 
throat  and  swollen  tonsils  on  the  i8th  of  January.  She 
was  given  the  mixture.  On  the  20th  of  January  membrane 
covered  the  tonsils,  and  was  continuous  over  the  walls 
of  the  pharynx.  The  mixture  was  ordered  in  larger 
doses,  and  at  more  frequent  intervals.     The  pulse  was 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM.   233 

full  and  bounding,  for  the  child  was  naturally  robust. 
On  the  evening  of  the  same  day  the  symptoms  had 
rapidly  grown  alarming  ;  the  voice  was  husky,  and  the 
breathing  was  becoming  difficult.  It  seemed  to  me  that 
the  ammonia  and  chlorate  of  potash  did  not  enter  the 
circulation.  I  prescribed  two  powders,  each  contain- 
ing two  grains  of  calomel  and  one-sixth  of  a  grain  of 
tartarized  antimony,  with  ten  grains  of  pulverized 
sugar,  to  be  given  at  an  interval  of  three  hours,  the 
mixture  to  be  given  in  the  meantime  every  half  hour, 
one  tablespoonful.  In  the  morning  she  was  weary,  but 
the  voice  was  clear,  the  breathing  was  improved,  and 
the  appearance  of  the  fauces  was  changed,  being  of  a 
brighter  red  color,  and  the  membrane  was  becoming 
detached.  She  continued  the  mixture  one  tablespoon- 
ful every  two  hours,  and  made  a  rapid  recovery,  for  on 
the  22d  she  was  fairly  convalescent. 

The  following  notes  were  made  by  Dr.  Cummings, 
the  able  House  Surgeon  of  the  Demilt  Dispensary,  in 
two  cases  lately  occuring  in  his  practice,  and  as  they 
are  independent  testimony,  coming  from  an  observer 
without  theory  or  prejudice,  I  offer  them  as  corrobo- 
rative of  the  value  of  the  mixture  of  muriate  of  ammo- 
nia and  chlorate  of  potash  as  a  remedy  in  serious  forms 
of  diphtheria. 

Case  I. — Diphtheria  a ffecti7ig  the  larynx  terminating  in 
recovery. — December  25th,  1863.  Saw  for  the  first  time 
a  boy,  August  Weber,  aged  three  years  and  four 
months,  who  had  been  ill  for  four  days,  complaining  of 
symptoms  referable  to  the  throat.  It  was  eleven 
o'clock  at  night  when  I  first  saw  him ;  parents  stated 
that  he  was  much  worse  this  evening  than  he  h^d  been 
previously.  Croupal  respiration  and  cough  were  both 
well  marked ;  face  expressive  of  much  anxiety  and  lips 
livid;  pulse  120  per  minute  and  weak.     The  submaxil- 


234  DISEASES  OF  ttlfe   MEAkt  AND   LUNGS. 

lary  region  was  much  swollen ;  the  voice  also  hoarse 
and  indistinct.  On  opening  the  mouth  the  tonsils  were 
seen  to  be  tumefied  and  covered  by  a  false  membrane 
of  a  whitish  color ;  the  pillars  of  the  palate  were  like- 
wise covered  with  false  membrane. 

From  the  fact  that  the  disease  was  so  advanced  and 
the  laryngeal  symptoms  so  severe,  an  unfavorable  prog- 
nosis was  given.  The  child  was  ordered  four  grains  of 
the  chloride  of  ammonium  and  one  and  one  fourth 
grain  of  the  chlorate  of  potassa  every  half  hour,  in  a 
teaspoonful  of  camphor  water,  also  five  drops  of  the 
chloride  of  iron  every  four  hours.  Fomentations  were 
likewise  directed  to  be  applied  to  the  neck. 

December  26th,  9  a.m.  Found  the  patient  a  Httle 
more  comfortable,  but  the  fauces  presented  pretty 
nearly  the  same  appearance  as  on  the  previous  night; 
the  face  was  very  pale,  but  had  not  quite  that  lividity 
which  was  observed  at  the  former  visit;  child  took 
liquid  food  greedily,  and  had  experienced  great  desire 
for  sleep  during  the  night.  The  same  medicines  were 
continued,  and  beef  tea  and  milk  punch  also  ordered. 
Saw  the  child  again  that  night ;  cough  and  breathing 
distinctly  laryngeal,  yet  the  obstruction  to  respiration 
did  not  seem  quite  so  great  as  on  the  preceding  night. 

December  27th.  Patient  was  decidedly  easier ;  had 
passed  a  tolerably  comfortable  night.  Respiration  less 
stridulous  ;  cough  had  a  little  more  of  a  moist  charac- 
ter ;  membranes  seemed  to  have  diminished  in  extent, 
and  to  appear  thinner  and  somewhat  detached  at  their 
edges;  appetite  still  good;  directed  to  continue  the 
same  medicine. 

On  the  29th  of  December  the  tonsils  and  throat  had 
become  completely  free  of  the  false  membranes,  and 
the  child  was  still  improving,  although  the  croupal 
cough  remained. 


tHERAPEUTICS   OF   CHLORIDE    OF   AMMONIUM.    23$ 

Chloride  of  ammonium  and  chlorate  of  potassa  were 
ordered  in  the  previous  doses  every  two  hours.  Qui- 
nine was  also  given  as  the  appetite  of  the  child  w  as  fail- 
ing ;  iron  continued. 

January  3d.  Bronchitic  rales  were  now  heard. 
These  disappeared  in  a  few  days  under  the  influence 
of  general  counter-irritation  and  expectorants.  The 
croupal  cough  continued  until  Jan.  7th,  when  it  had 
entirely  disappeared  and  the  child  was  dismissed  from 
my  care,  with  directions  to  take  the  iron  a  week  longer. 
Since  then  I  have  heard  from  the  child,  who  remains  in 
perfect  health.  I  would  add  there  were  in  the  house 
where  this  boy  lived  four  other  children  suffering  with 
pharyngeal  diphtheria,  under  my  care,  at  nearly  the 
same  time,  all  of  whom  recovered,  the  same  treatment 
having  been  pursued. 

Case  II. — Diphtheria  involving  the  larynx  terminating 
fatally. — December  30th,  1863.  Was  called  to  see 
Margt.  Quinn,  aged  four  years  and  eight  months.  This 
child  had  been  suffering  with  sore  throat  five  days ; 
could  not  learn  that  she  had  experienced  any  fever. 

This  patient  exhibited  decided  stridulous  breathing, 
inspiration  and  expiration  being  both  very  much  pro- 
longed, a  ringing  croupal  cough,  and  the  voice  was 
quite  extinguished.  The  lips  were  livid,  the  eyes 
prominent,  the  head  thrown  back,  and  the  whole  ex- 
pression one  of  great  distress.  The  pulse  was  frequent 
and  feeble.  On  inspecting  the  fauces,  a  dense  grayish 
white  membrane  was  seen  covering  the  tonsils  and 
pillars  of  the  palate,  not  patchy,  but  continuous ;  there 
were  also  bridles  across  the  posterior  pharyngeal  wall, 
and  the  uvula  was  enveloped  by  a  layer  of  membrane. 

An  unfavorable  prognosis  was  made  in  this  case. 
Death  seemed  imminent  from  the  obstruction  in  the 
larynx. 


236  DISEASES   OF  THE   HEART  AND   LUNGS. 

The  patient  was  given  five  grains  of  chloride  of  am- 
monium and  one  grain  and  a  fourth  of  chlorate  of 
potassa  every  half  hour,  in  a  teaspoonful  of  syrup  and 
water.  Five  drops  of  the  chloride  of  iron  were  given, 
in  the  same  vehicle,  every  four  hours  ;  milk  punch  and 
beef  tea  were  also  ordered.  The  next  day,  when  the 
child  was  visited,  its  general  appearance  had  a  little 
improved,  although  it  had  experienced  several  attacks, 
threatening  suffocation,  during  the  night.  The  respi- 
ration seemed  a  little  less  difficult  than  on  the  preced- 
ing day ;  not  much  change  was  observed  in  the  condi- 
tion of  the  throat.  The  respiration  now  continued 
steadily  to  improve,  and  on  the  2d  of  January  the 
membrane  was  evidently  disappearing  on  all  parts 
accessible  to  the  eye.  The  chloride  of  ammonium 
and  chlorate  of  potassa  were  now  given  in  half  of 
their  previous  doses.  The  iron  was  continued  as 
before.  As  soon  as  the  difficulty  of  respiration  was 
somewhat  relieved,  the  child  exhibited  a  great  ten- 
dency to  sleep,  both  day  and  night  showing  the  severe 
toxasmic  effect  of  the  diphtheritic  virus. 

On  January  4th  no  membrane  was  visible,  and  the 
breathing  of  the  child  had  become  perfectly  calm ;  all 
cough  had  likewise  disappeared.  There  was  now 
noticed  on  the  left  tonsil  a  small  perforating  ulcer,  look- 
ing as  though  it  were  bored  or  punched  into  the  gland. 
There  was  also  paralysis  of  the  muscles  of  the  palate, 
occasioning  much  difficulty  in  swallowing,  producing 
a  cough  and  regurgitation  of  food  through  the  nostrils ; 
a  muco-purulent  discharge,  at  times  streaked  with 
blood,  also  issued  from  the  nostrils.  Quinine,  in  ad- 
dition to  the  iron,  milk  punch  and  beef  tea,  was  now 
given;  the  chloride  of  ammonium  and  chlorate  of 
potassa  were  discontinued.  Jan.  6th  the  ulcer  con- 
tinued to  increase  in  extent  and  depth,  and  other  ulcers 


THERAPEUTICS   OF  CHLORIDE  OF  AMMONIUM.   237 

were  seen  starting  around  the  original  one ;  discharge 
from  the  nostrils  more  streaked  with  blood ;  moist 
bronchitic  rales  were  now  heard  for  the  first  time,  ap- 
parently not  much  embarrassing  the  respiration.  Pa- 
tient continued  weak,  but  took  medicine  and  nourish- 
ment very  well.  For  the  bronchitis  gentle  counter-ir- 
ritation to  the  chest,  and  stimulating  expectorants  were 
employed. 

January  8th.  *  Rales  distinctly  heard,  seemed  to  in- 
volve the  smaller  bronchial  tubes  on  one  sidfe ;  no 
dulness  on  percussion ;  no  great  difficulty  in  respira- 
tion; child  pale  and  weak;  pulse  frequent  and  feeble; 
same  treatment  continued,  with  injunctions  to  give  an 
additional  amount  of  stimulants. 

January  9th.  Visited  the  child  at  12  M.,  who  seemed 
rather  more  comfortable  than  the  day  before.  The 
child  continued  quite  comfortable,  as  I  understood  by 
the  parents,  until  6  p.m.,  when  immediately  after  taking 
food  it  died,  dropping  off  as  though  in  a  state  of  syn- 
cope. 

These  two  cases  seem  to  me  to  illustrate  the  efficacy 
of  chloride  of  ammonium  in  promoting  the  separation 
of  the  diphtheritic  membranes  as  well  as  in  relieving  the 
swollen  condition  of  the  parts  on  which  they  rest.  In 
the  last  case  the  relief  to  the  laryngeal  obstruction  com- 
menced almost  immediately  upon  its  administration, 
although  the  child  subsequently  died  of  blood-poison- 
ing. 

I  am  in  the  habit  of  employing  it  in  all  cases  of  diph- 
theria, as  I  know  of  nothing  that  answers  the  above- 
mentioned  indications  equally  well." 

Isaac  Cummings,  M.  D. 

Demilt  Dispensary,  Feb.  ist,  1864. 

*  These  rales  were  undoubtedly  interpleural  plastic,  but  at  that  time  I 
had  not  yet  learned  their  true  signification  nor  had  Dr.  Cummings, 


238  DISEASES   OF  THE   HEART  AND   LUNGS. 

I  have  been  constantly  in  the  habit  of  giving  muri- 
ate of  ammonia,  alone  or  in  combination,  in  all  forms 
of  inflammation,  not  depriving  myself,  however,  of  the 
choice  of  more  actively  efficient  agents  when  the  cases 
seemed  to  require  them. 

In  pneumonia  it  acts  promptly  and  efficiently,  and 
also  in  sub-acute  pleuritis  ;  in  congestion  of  the  brain  it 
frequently  affords  prompt  relief.  Even  in  acute  men- 
ingitis of  children  it  acts  with  apparent  benefit,  lowering 
the  pulse  and  preventing  convulsions.  In  tubercular 
diseases  of  all  forms  I  deem  it  decidedly  beneficial, 
and  especially  in  phthisis.  During  the  last  five  years  I 
have  had  large  experience  with  the  muriate  of  ammo- 
nia as  a  remedy  in  tubercular  phthisis  at  the  Demilt 
Dispensary,  in  the  class  of  chest  diseases,  with  the  re- 
sult of  confirming  my  confidence  in  its  remedial  power. 
No  other  single  agent  has  been  so  beneficial  in  my 
hands.  I  prescribe  it  with  wild  cherry  bark  in  cold  in- 
fusion given  at  frequent  intervals.* 

I  believe  muriate  of  ammonia  to  be  essentially  a 
blood  medicine ;  it  must  enter  the  circulation  to  pro- 
duce its  effect,  and  this  is  the  only  explanation  I  have 
to  offer  for  its  apparent  benefit  in  diseases  of  such  oppo- 
site types.  I  believe  it  acts  as  a  catalytic  and  also  as  a 
resolvent ;  that  as  a  catalytic  it  accomplishes  its  work 
of  arresting  inflammatory  action  without  any  such 
destruction  of  blood  corpuscles  as  is  done  by  mercury. 

Mialhi  estimates  that  one  third  of  the  blood  corpus- 
cles of  the  body  are  destroyed  by  placing  the  system 
under  the  influence  of  mercury.  If  that  be  true,  chlo- 
ride of  ammonium  is  much  the  safer  agent,  especially  in 
debilitated  constitutions.     As  a  resolvent  it  is  believed 


*  5  Ammon   chlor.  §  i.  cont.   P.  Virgin,    ^  ij.    M.   Cold   infusion  by 
percolation  two  pints,  S.  one  tablespoonful  every  hour, 


THERAPEUTICS   OF  CHLORIDE   OF  AMMONIUM.   239 

by  German  physicians  to  act  upon  glandular  swellings 
and  recent  tubercle,  and  my  favorable  experience  with 
it  leads  me  to  adopt  that  view. 

I  have  mostly  used  it  as  an  internal  medicine,  but  in 
some  cases  I  have  thought  it  produced  good  effects  in 
the  bath.  *'  Dr.  Giesler  used  it  in  the  form  of  vapor 
by  inhalation  in  chronic  catarrh  and  never  found  it 
useless."  He  also  recommends  it  in  some  forms  of 
rheumatism,  and  in  strumous  ophthalmia.  Dr.  Noegge- 
rath,  of  New  York,  has  used  the  vapor  of  muriate  of 
ammonia  successfully  in  some  cases  of  diphtheria.  It  is 
readily  vaporized  by  placing  it  on  a  hot  metallic  sur- 
face, and  it  strikes  me  that  this  mode  of  using  it,  in 
some  cases  at  least,  must  be  preferable  to  any  other. 

Some  years  ago.  Dr.  Batchelder,  of  New  York,  men- 
tioned to  me  that  the  iodide  of  potassium  was  more 
energetic  and  produced  its  characteristic  effects  in 
much  less  time  than  usual,  when  mixed  with  an  equal 
or  larger  amount  of  chloride  of  ammonium.  I  have 
satisfied  myself  many  times  since  of  this  fact,  and  also 
that  it  energizes  the  action  of  other  remedies  when  in 
combination,  as  in  chlorate  of  potass.,  nitrate  of  potash 
and  the  muriated  tincture  of  iron.  A  mixture  of  muri- 
ate of  ammonia,  nitrate  of  potash  and  senega  root, 
colored  with  cochineal,  is  sold  as  a  common  remedy  for 
influenza  or  cold  in  the  head,  I  am  told,  from  the  drug- 
shops  in  the  towns  along  the  upper  part  of  the  Hudson 
River.  It  was  a  favorite  prescription  of  the  late  Dr. 
White  of  Hudson,  and  is  known  as  "  White's  Red 
Salts."  Half  an  ounce  each  of  these  articles,  with 
liquorice  root  to  disguise  the  taste,  may  be  infused  in  a 
pint  of  water ;  dose  one  tablespoonful  every  fifteen 
minutes  for  an  hour  or  two  before  going  to  bed  gener- 
ally relieves  a  patient  with  commencing  influenza,  and 
he   awakes   in   the   morning   well.     All   surgeons   are 


240  DISEASES   OF   THE   HEART  AND    LUNGS. 

aware  with  what  energy  a  saturated  solution  of  muriate 
of  ammonia  and  bichloride  of  mercury  will  act  as  an 
escharotic. 

Muriate  of  ammonia  has  been  held  in  high  estimation 
by  German  physicians  for  more  than  a  hundred  years. 
At  the  close  of  the  last  century  Gmelin  said  of  it,  ''  that 
it  is  by  far  the  most  powerful  of  saline  preparations, 
whether  as  an  internal  or  external  agent."  "  Bocker 
considers  its  therapeutical  action  to  depend  upon  its 
quickening  the  moulting  or  waste  of  mucous  membrane, 
and  on  this  account  its  protracted  use  in  young  people 
especially  is  to  be  avoided."  This  view  I  believe  to  be 
mere  hypothesis,  for  it  is  not  borne  out  by  my  experience. 
*'  Osterlin  states  that  by  mistake  one  of  his  patients  took 
two  ounces  of  muriate  of  ammonia  at  a  single  dose 
without  any  other  result  than  trifling  colic  and  some 
watery  stools."  *'  It  is  praised  by  Gmelin  for  its  effi- 
cacy in  intermittent  fevers."  "  In  185 1  M.  Aran  ex- 
perimented with  it  and  considers  that  the  results  indi- 
cated that  it  possessed  some  and  not  a  little  power  over 
intermittent  fevers."  "  Jacquot,  also,  in  185 1-2  used  it 
in  treating  soldiers  of  the  French  army  occupying 
Rome.  The  results  consisted  in  the  abrupt  cessation 
of  the  paroxysms  in  six  out  of  twenty-one  cases,  but  in 
two  of  the  six  cases  the  attacks  returned." 

In  1855  Dr.  Alexander  Lindsay  published  in  the 
Glasgow  Medical  Journal,  an  article  on  the  "  Physio- 
logical and  Therapeutical  effects  of  the  Chloride  of 
Ammonia."  "  Dr.  Lindsay  and  two  intelligent  pupils 
made  experiments  on  themselves,  taking  the  chloride 
in  medicinal  doses,  being  in  a  state  of  health,  and  care- 
fully regulating  their  diet,  etc.  On  the  second  day 
after  beginning  the  medicine  a  buoyancy  of  the  system 
was  experienced  that  rendered  the  ordinary  pursuits  a 
pleasure,  and  fitted  the  body  and  mind  for  increased 


THERAPEUTICS   OF   CHLORIDE   OF  AMMONIUM.    241 

exertion."  "  The  feculant  discharges  were  in  all  much 
augmented,  the  appetite  was  much  improved.  In  two 
the  force  and  frequency  of  the  heart's  action  were  di- 
minished. The  rate  of  the  pulse  in  the  gentleman  em- 
ploying the  smallest  dose  was  accelerated.  In  all  the 
urinary  secretion  was  increased.  The  dose  was,  in  one 
18  grains  per  day  ;  the  second,  I3-J  grains,  and  the  third 
nine  grains."  This  is  the  only  record  that  I  am  aware 
of  in  which  experiments  have  been  made  with  chloride 
of  ammonia  on  healthy  persons.  Dr.  Lindsay  used  the 
remedy  in  many  and  various  diseases,  and  is  much 
pleased  with  the  results.  He  combined  it  with  tartar- 
ized  antimony  and  morphia.  Dr.  Walshesays,  ''Muriate 
of  ammonium  has  appeared  to  me  to  be  useful  in  two  ap- 
parently opposite  ways — by  promoting  expectoration 
when  deficient,  by  controlling  its  amount  when  exces- 
sive." In  the  "  Astley  Cooper  Prize  Essay,"  for  1856, 
on  "  The  Cause  of  Coagulation  of  the  Blood,"  by  B.  W. 
Richardson,  M.  D.,  it  is  shown  by  a  number  of  experi- 
ments that  fresh-drawn  blood  gives  off  free  ammonia 
during  the  process  of  coagulation.  .  It  is  also  shown 
that  the  addition  of  ammonia  to  the  blood  retards  the 
coagulation  according  to  the  amount  used ;  that  am- 
monia added  to  coagulated  blood  will  cause  j^t  to  again 
become  fluid,  and  that  it  will  again  become  coagulated 
when  the  added  ammonia  has  passed  off  in  vapor. 
"  That  ammonia  is  evolved  from  the  blood,"  says*  his 
reviewer,  "  on  its  being  withdrawn  from  the  vessels 
and  exposed  to  the  air,  has  been  proved  most  satisfaC' 
torily  by  Dr.  Richardson's  experiments,  which  have 
been  so  multiplied  and  varied  as  to  exclude  all  sources 
of  fallacy." 

These  experiments  go  to  show  that  ammonia  is  neces- 
sary to  healthy  blood  ;  that  in  excess  it  is  rapidly  thrown 
off  in  th^  excretions,  and  in  this  w^y  it  is  not  allowed  to 


242  DISEASES   OF  THE   HEART  AND   LUNGS. 

accumulate  unduly  ;  that  ammonia,  taken  into  the  system 
in  whatever  form,  is  thrown  off  as  free  ammonia,  and 
this  may  explain  why  its  combination  with  other  agents 
so  increases  and  energizes  their  characteristic  effects. 

Dr.  Ozier  Ward,  in  the  ''  London  Lancet  for  April, 
1859,"  says:  ''Ammonia  had  never  been  considered  to 
be  a  normal  constituent  of  the  blood,  as  its  presence 
had  not  been  detected  except  after  death,  in  cases  of 
typhus,  cholera,  melaena,  and  other  diseases  of  a  putrid 
character,  until  Dr.  Richardson's  recent  discovery  that 
healthy  blood  owes  its  fluidity  to  the  presence  of  am- 
monia.'* In  speaking  of  its  therapeutical  effects,  he 
says,  finally :  "  The  hydrochlorate,  which  is  the  least 
easily  decomposed,  is  probably  the  most  useful  of  the 
salts  of  ammonia,  as  it  not  only  possesses  the  stimulant, 
resolvent,  secernent  properties  of  the  others,  but,  owing 
to  its  combination  with  chlorine,  is  endued  with  tonic 
powers,  by  which  its  prolonged  use,  unlike  that  of  the 
other  preparations,  is  attended  with  invigorating  effects 
both  to  mind  and  body,  and  that  it  forms  an  excellent 
substitute  for  mercury  in  cases  where  this  medicine  is 
inadmissible  from  its  tendency  to  produce  cachexia." 

Perhaps  this  record  of  my  own  experience,  with  notes 
of  that  of  other  observers  at  different  times  and  in  dif- 
ferent places,  may  help  to  show  that  muriate  of  am- 
monia, known  to  the  ancients,  much  valued  by  the 
Arabian  physicians  of  the  middle  ages,  and  again  intro- 
duced into  practice  by  German  physicians  a  century 
ago,  is  still  upon  trial,  and  that  facts  are  accumulatmg 
which  promise  to  elevate  it  into  a  promment  place  in 
our  pharmacopoeia.* 

*  After  so  many  years  since  the  publication  of  this  article  I  have  it  still 
in  constant  use.  In  cold  infusion  of  wild  cherry  bark,  sixteen  to  twenty 
grains  to  the  ounce,  half  ounce  doses  of  the  mixture,  it  is  of  great  ser- 
vice in  interpleural  plastic  exudation,  and  in  the  early  stages  of  fibroid 
phthisis.     Many  cases  get  well  with  no  other  medication. 


IS  CONSUMPTION  COMMUNICABLE?  243 


XII. 

Is  Consumption  Communicable?* 

From  the  earlier  days  of  medicine  to  the  present  time 
there  has  ever  been  a  popular  belief  that  consumption 
is  communicable.  Such  a  widespread  and  general  opin- 
ion, continuing-  for  ages  and  in  many  countries,  must 
have  some  foundation  in  fact.  Cases  of  consumption 
have  followed  each  other  under  circumstances  which 
have  impressed  observers  as  proof  of  its  infectious  char- 
acter ;  as  when  a  husband  or  wife  has  watched  with  the 
deepest  solicitude  the  long-continued  and  vacillating 
illness  of  the  other,  to  be  finally  overwhelmed  with 
grief  at  the  fatal  result,  and  then  to  sicken  and  die  un- 
der similar  conditions. 

The  profession  has  at  times  inclined  to  the  popular 
faith,  and  again  has  rejected  it. 

The  discovery  of  true  tubercle  by  Bayle  in  1804,  and 
of  the  methods  and  value  of  auscultation  by  Laennec, 
published  in  18 19,  threw  new  light  upon  diseases  in- 
cluded under  the  common  name  of  consumption.  It 
did  more — it  filled  the  professional  mind  with  the  idea 
of  tubercle,  to  the  exclusion  of  other  and  common  forms 
of  consumptive  diseases. 

The  very  important  doctrines  taught  by  Broussais,  in 
Laennec's  time,  because  they  were  not  all  of  tubercle, 
were  overshadowed,  obscured,  and  misunderstood. 
The  immense  advantage  of  physical  diagnosis  by  auscul- 
tation and  percussion  in  getting  a  true  mental  picture 
of  the  pathological  conditions  of  the  chest  was  certainly 

*  New  York  Medical  Jmirital,  December  i,  1883. 


244  DISEASES   OF  THE   HEART  AND   LUNGS. 

weakened  by  the  adoption  of  the  exclusive  doctrine  of 
tuberculosis. 

The  erroneous  interpretation  of  the  respiratory  act 
and  of  the  significance  of  its  murmurs,  as  taught  by 
Laennec  and  his  followers,  confirmed  them  in  the  patho- 
logical error  that  all  forms  of  consumption  must  neces- 
sarily be  tuberculous.  But  the  fashion  of  careful  post- 
mortem examination  grew  in  favor,  and  the  microscope 
vastly  extended  our  knowlededge  of  pathological  re- 
sults, and  has  established  the  fact  that  the  tubercular 
is  not  the  only  form  of  phthisis.  Still  we  are  groping 
among  the  debris  of  protoplasm,  cells,  and  proliferation, 
anxiously  searching  for  the  specific  evidence  of  tuber- 
culosis as  an  entity  self-existent  and  self-propagating — 
something  which  has  a  separate  life  from  the  life  of  the 
body,  and  which  is  independent  of  it,  antagonistic  to  it, 
and  which  overcomes  it. 

This  view  differs  from  that  which  considers  con- 
sumption, either  tubercular  or  fibroid,  as  inherent  in 
the  life  of  the  body,  which  is  excited  to  activity  by  irri- 
tation or  depression,  either  physical  or  mental. 

It  is  said  that  the  giant  cell  characterizes  tubercle  and 
the  spindle-shaped  cancer,  and  that  by  them  we  are  able 
to  distinguish  tubercular  and  cancerous  products.  But 
this  knowledge  of  them  does  not  determine  the  life-pro- 
ducing origin  of  tubercle  nor  that  of  cancer;  whether  they 
have  a  distinct  life  outside  the  life  of  the  body,  and  have 
only  an  accidental  connection  with  it,  or  whether  these 
morbid  cell-forms  are  merely  the  materialized  expres- 
sion of  disease-action  of  the  immaterial  life  of  the  body. 
Animals  have  been  experimented  upon  by  inoculation 
of  tuberculous  matter,  and  tubercle  has  been  the  result, 
and  it  has  been  claimed  that  the  question  was  solved  in 
the  affirmative.  But,  again,  these  same  animals  were 
inoculated  with  non-tuberculous  matter,  and  the  result 


IS  CONSUMPTION   COMMUNICABLE?  245 

was  tubercle,  proving-  that  the  character  of  the  inocu- 
lated matter  had  nothing  to  do  with  the  tuberculated 
results,  but  that  irritation  was  the  sole  cause,  and  the 
result  would  be  tubercle  or  cancer,  according  to  the 
inherent  tendency  of  the  individual  either  to  tubercle 
or  to  cancer.  The  irritation  of  teething  endangers 
tubercular  meningitis  in  children,  and  tuberculated 
phthisis  may  result  from  the  irritation  of  adhesions  of 
the  pleura.  Had  not  this  theory  of  tubercular  inocu- 
lation disestabhshed  itself  by  these  experiments,  it  would 
still  remain  an  essential  fact  that  inoculation  is  not  in- 
fection, that  poisoning  the  system  by  inoculation  of  any 
materies  morbi  is  not  conveying  a  germinating  parasite 
into  healthful  respiratory  organs,  and  producing  disease 
in  them  of  its  own  kind.  But  lately  the  medical  world 
has  been  set  wild  by  the  publication  of  the  discovery  of 
Professor  Koch  of  the  presence  of  bacilli  in  tubercular 
cavities  and  in  tubercular  sputa. 

It  has  been  shown,  too,  by  experiment  that  these  in- 
dependent life-forms  may  propagate  themselves  outside 
the  body  and  in  other  menstrua  than  the  debris  of  de- 
caying tubercular  cavities.  ^       , 

These  facts  appear  to  be^demonstrated  and  accurately 
proved  by  other  careful  observers.  But  the  deductions 
of  Professor  Koch  are  that  these  self-producing  life- 
forms  are  the  cause  of  tuberculosis  and  of  tubercle,  and 
propagate  their  kind  in  a  healthful  human  lung,  and, 
thence  taking  wings,  are  carried  to  and  transplanted  in 
other  healthful  lungs.  Their  propagation  being  rapid 
and  abundant,  and  the  medium  of  their  conveyance  the 
air  we  breathe,  the  danger  therefrom  becomes  appal- 
ling to  fearful  minds,  who  dread  the  ravages  of  this 
most  deadly  of  human  diseases.  To  be  entirely  consist- 
ent, the  germ  theorists  must  deny  the  influence  of 
heredity  and  external  conditions,  of  local  irritations  or 


246  iDtSEASES   OF  THE  HEART  AND   LUNGS. 

the  depression  of  vital  dynamics,  as  causes  of  consump- 
tion. 

If  it  were  not  for  the  adoption  of  Professor  Koch's 
theories,  as  well  as  the  acknowledgment  of  his  dis- 
covery of  bacilli  by  gentlemen  of  high  scientific  attain- 
ments, such  as  Professor  Riihle,  of  Bonn,  and  others, 
controversy  would  be  unnecessary  ;  but,  as  it  is,  we 
must  examine  the  subject  critically  but  dispassionately. 

So  far  as  I  am  aware,  fibroid  phthisis  is  not  included 
in  the  forms  of  consumption  claimed  to  be  propagated 
by  bacilli.  The  germ  theorists  appear  to  assume  that 
all  forms  of  phthisis  are  tubercular.  But  a  large  num- 
ber of  cases  are  fibroid,  pure  and  simple,  in  which 
the  diathesis  is  gouty  or  rheumatic,  and  not  scrofulous. 
This  large  number  are  exempt  from  suspicion  even. 
Again,  a  vast  majority  of  cases  of  tuberculated  phthisis 
commence  with  plastic  exudation  within  the  pleural 
cavity.  These  are  called  by  Niemeyer  ''  catarrhal  pneu- 
monia," and  he  says  "the  great  fear  is  that  they  may 
become  tubercular.'*  This  fear  is  born  of  experience, 
and  should  direct  us  to  proceed  energetically,  at  the 
same  time  judiciously,  to  remove  the  plastic  exudation 
while  it  is  easy  of  accomplishment.  Now,  as  long  as 
the  cases  are  not  tuberculated  nor  tubercular,  they  can- 
not be  influenced  by  bacilli,  for  as  yet  there  is  no  nest 
prepared  for  them.  It  may  be  well  to  state  here  that 
we  make  a  distinction  between  tuberculosis  and  tubercu- 
lated phthisis.  Tuberculosis  is  the  systemic  disease 
which  gives  birth  to  true  tubercle — the  miliary  tubercle 
of  Bayle.  Tuberculated  phthisis  is  the  result  of  cheesy 
degeneration,  in  which  cavities  take  place  as  a  result  of 
tuberculosis  or  other  causes.  The  number  of  uncom- 
plicated cases  of  tubercular  phthisis — that  is,  of  tubercle 
forming  into  concretions  or  nodules  and  being  encapsu- 
lated, with  no  pleuritic  adhesions  and  without  fibroid 


IS  CONSUMPTION  COMMUNICABLE?  247 

in  the  lung,  is  extremely  small.  In  a  practice  of  more 
than  thirty  years  in  dispensary,  hospital,  and  private,  I 
cannot  remember  more  than  a  very  few  cases.  Laennec 
and  Louis  evidently  refer  to  these  cases  under  the  term 
of  latent  phthisis  and  acute  phthisis. 

This  small  number,  commencing  centrally  in  the  lungs 
and  not  involving  the  pleura,  are  the  only  ones  which 
could  have  had  a  parasitic  origin.  But  even  in  these 
it  is  doubtful  whether  bacilli  have  anything  to  do  with 
their  tubercular  origin. 

I  do  not  doubt  the  discovery  of  bacilli  in  tubercolous 
cavities  nor  in  the  sputa  of  tubercular  consumptives, 
but  I  cannot  accept  the  inference  that  they  are  the  es- 
sential causes  of  tubercle.  They  may  find  in  a  tubercu- 
lous cavity  a  fit  soil  or  home  where  they  may  grow  and 
multiply.  There  may  be  spores,  eggs,  germs,  laid  there 
by  their  parents,  which,  when  perfected,  may  fly  away 
to  seek  other  tuberculous  cavities  in  which  to  lay  their 
eggs,  etc. 

Is  there  not  analogy  in  the  green-bottle  fly  that  seeks 
carrion  in  which  to  lay  its  eggs,  where  they  are  hatched 
into  maggots,  which  may  increase  the  rapidity  of  the 
destruction  of  the  carrion  during  their  growth,  but, 
becoming  full-grown — they  fly  away  to  seek  other  car- 
rion to  plant  their  eggs,  and  thus  continually  propagate 
their  race  ? 

The  bacillus  of  Professor  Koch  may  be  the  maggot 
state  of  a  distinct  life,  born  of  an  egg  or  germ,  and  may 
perfect  itself  into  another  form  which  may  fly  away  to 
find  other  tuberculous  cavities,  fit  homes  for  the  propa- 
gation of  its  kind,  as  germs,  bacilli,  and  of  the  perfected 
life-form  which  will  again  fly  away  to  find  other  tuber- 
culous homes. 

It  is  not  probable,  nor  according  to  analogy,  that  the 
bacillus  was  always  in  that  state,  or  that  it  will  always 


248  DISEASES   OF  THE   HEART  AND   LUNGS. 

remain  as  such,  to  be  transplanted  to  healthful  lungs 
and  to  cause  tuberculosis ;  for  it  is  not  the  disease,  but  a 
parasitic  life  which  grows  and  perfects  itself  in  the  de- 
cay and  debris  of  tuberculous  cavities.  It  may  increase 
the  rapidity  of  decay  in  the  necrosed  lung,  as  the  mag- 
got does  in  the  carrion,  and  it  is  our  duty  to  prevent 
this  if  we  have  the  knowledge  and  the  power.  But  the 
bacillus  is  not  necessary  to  explain  the  occurrence, 
cause,  and  course  of  phthisis — fibroid  or  tubercular. 
As  has  been  stated,  all  but  a  very  small  number  of  cases 
commence  as  fibroid — that  is,  with  plastic  exudation 
within  the  pleura,  in  which  the  bacillus  is  not  a  factor. 
This  primary  condition  of  phthisis  may  be  the  result  of 
depressed  vital  power  from  various  causes,  long-con- 
tinued and  violent  emotion,  anxiety,  worry,  grief,  or 
disappointment,  as  well  as  from  catarrhal  causes.  Or 
it  may,  but  in  a  less  degree,  be  the  result  of  adhesions 
from  acute  pleurisy,  which  are  a  physical  cause  of  vital 
depression. 

A  mother,  after  watching  her  children,  three  or  four 
in  number,  through  scarlatina  of  a  severe  type,  began 
to  cough,  lose  weight,  and  finally  died  of  phthisis.  She 
was  well  when  the  children  were  taken  ill ;  she  was  a 
loving,  anxious  mother,  and  as  they  were  attacked  suc- 
cessively the  time  of  her  anxiety  was  prolonged.  The 
children  all  recovered,  but  the  mother  was  sacrificed. 
She  was  not  aware  of  having  taken  cold.  The  cough  was 
so  insidious  that  no  one  could  tell  when  it  commenced. 
Had  there  been  the  same  prolonged  anxiety  over  a  case  of 
phthisis,  followed  by  inconsolable  despair  at  the  loss  of 
the  loved  one,  it  would  have  seemed  to  prove  the  com- 
municability  of  consumption.  Scarlatina  germs  do  not 
originate  phthisis,  nor  do  bacilli — it  is  the  result  of 
natural  causes. 

Failure  in  business  after  a  prolonged  struggle  in  a  con- 


IS  CONSUMPTION  COMMUNICABLE?  249 

scientious  man  may  be,  and  frequently  is,  followed  by 
phthisis.  Disappointment  in  the  young,  where  there 
is  intensity  of  grief,  is  often  followed  by  phthisis.  In 
all  of  these  cases,  whether  fibroid  or  tuberculated,  the 
disease  commences  with  plastic  exudation  within  the 
pleurae. 

Even  in  tubercular  phthisis,  for  a  considerable  time 
the  disease  is  simply  fibroid — preventable  phthisis. 

One  word  for  the  poor  consumptive.  Morbidly  sen- 
sitive to  all  unpleasant  sights,  smells,  and  surroundings, 
and  whose  greatest  comfort  is  kind  and  sympathizing 
companionship,  is  it  not  the  refinement  of  cruelty  to 
drive  away  from  him  unnecessarily"  those  who  should 
minister  to  his  suffering  ? 

Quotations  from  Current  Literature  in  regard  to  Bacilli^ 
with  Notes  by  D.  M,  Cammann^  M,D. 

On  March  24,  1882,  Dr.  Robert  Koch  communicated 
to  the  Physiological  Society  of  Berlin  the  result  of  a 
series  of  elaborate  investigations  into  the  etiology  of 
tuberculosis. 

He  believes  tuberculosis  to  be  caused  by  a  parasite, 
the  parasite  being  a  bicillus  and  being  distinguished 
from  other  bacilli  by  its  behavior  towards  the  coloring 
agent  **vesuvin."  The  tubercle  bacillus  is  slender, 
rod-shaped,  about  five  times  as  long  as  it  is  broad,  and 
varying  in  length  from  one  quarter  to  the  whole  dia- 
meter of  a  red  blood  corpuscle.  The  method  pursued 
in  finding  the  bacillus  was  as  follows  :  "The  tuberculous 
substance  was  either  spread  out  upon  a  cover-glass, 
dried  and  exposed  to  heat,  or  a  piece  of  tuberculous 
organ  was  placed  in  alcohol,  and  afterwards  cut  into 
fine  sections.  A  particular  solution  of  methylene-blue 
was  made,  a  weak  solution  of  potash  being  added,  the 
cover-glass  coated  with  tuberculous  matter  (or  a  section 


250  DISEASES   OF  THE   HEART  AND   LUNGS. 

of  the  organ)  was  then  placed  in  the  solution  for  twenty 
or  twenty-four  hours,  but  half  an  hour  sufficed  if  the 
solution  were  warmed  in  a  water-bath  up  to  40°  C. 
The  cover-glass,  which  comes  out  a  deep  blue,  is  then 
treated  with  a  concentrated  watery  solution  of  *  vesur 
vin'  for  one  or  two  minutes,  and  is  afterwards  washed 
with  distilled  water.  The  blue  of  the  mythelene  has 
visibly  changed  to  brown  ;  under  the  microscope  all  the 
amorphous  detritus  and  fragments  of  tissue  spread  out 
on  the  glass  are  brown,  but  the  tubercle  bacteria  remain 
blue!' — Braithwaite  s  Retrospect,  July,  1882. 

The  bacillus  was  oftenest  found  in  the  interior  of 
giant  cells.  Not  every  giant  cell  or  group  of  cells  con- 
tained it,  but  those  which  were  free  were  old  cells 
which  had  once  held  bacilli  and  had  gotten  rid  of  them. 
They  may  become  few  or  disappear  entirely.  They  are 
usually  found  in  large  numbers  in  cavities.  To  show 
that  the  bacillus  is  the  cause,  and  not  a  mere  accom- 
paniment, of  tuberculosis,  Koch  proceeded  to  separate 
it  from  other  substances  by  a  series  of  "  cultivations." 
He  took  the  blood-plasma  of  the  ox  or  the  sheep,  and 
after  repeated  applications  of  heat,  he  boiled  it  to  a 
coagulum,  ''  at  the  same  time  inclining  the  test-tube  so 
that  the  coagulum  might  cover  a  considerable  surface. 
It  was  on  this  nutrient  soil  that  he  proposed  to  *  grow' 
the  tubercle-bacillus  without  the  intervention  of  moist- 
ure." After  taking  a  piece  of  tuberculous  substance 
— usually  from  the  lung  of  the  ape  or  of  man — and  care- 
fully washing  it  several  times  in  a  solution  of  corrosive 
sublimate,  the  outer  layer  was  removed,  and  from  within 
was  taken  a  portion  '^  into  which  it  was  to  be  expected 
that  no  bacteria  of  putrefaction  had  penetrated."  The 
piece  of  tuberculous  substance  was  then  broken  up  and 
thrown  over  the  surface  of  the  coagulum,  and  the  test- 
tube  kept  at  a  uniform  temperature  of  37°  to  38°  C.    If 


IS   CONSUMPTION   COMMUNICABLE?  2$ I 

during  the  first  week  any  activity  showed  itself,  it  was 
supposed  that  the  bacteria  of  putrefaction  were  present, 
and  the  experiment  was  not  continued.  Usually  about 
the  tenth  day  could  be  seen  on  the  surface  of  the  coagu- 
lum  "  a  number  of  very  small  points  or  dry-looking 
scales  which  surrounded  the  pieces  of  tubercle  that  had 
been  laid  out,  in  circuits  more  or  less  wide,  according 
to  the  extent  of  breaking  up  and  dispersion  of  the 
tubercle  fragments  at  the  time  when  they  were  sown.' 
These  dry  scales  were  taken  to  be  colonies  of  the  ba- 
cillus. After  a  few  weeks  the  scales  cease  to  enlarge, 
and  they  are  transferred  on  heated  platinum  wire  to 
another  test-tube  prepared  in  a  similar  manner.  This 
series  of  '*'  cultivations"  is  continued  through  ten  or  a 
dozen  times,  and  for  a  period  of  four  or  five  months. 
With  these  dry  scales  numerous  animals  were  inocu- 
lated, and  without  a  single  exception  all  the  inoculated 
animals  acquired  tuberculosis,  the  tubercles  having  the 
structure  of  the  original  tubercle.  Dr.  Koch  claims 
that  these  results  are  due  to  the  introduction  of  the  ba- 
cillus per  se. 

Since  Koch  announced  his  discovery  his  experiments 
have  been  repeated  by  several  observers.  That  the 
bacillus  is,  as  a  rule,  found  in  the  spute  of  persons  hav- 
ing tubercular  phthisis  is  confirmed  by  Ziehl,  Fraentzel 
and  Balmer,  Belfield,  Hierchfelder,  and  many  others. 
Dr.  Spina  of  Vienna,  while  agreeing  with  Koch  in 
always  finding  bacilli  in  the  sputa,  denies  that  they  oc- 
cur constantly  in  the  tuberculous  organs  of  man.  He 
could  never  find  them  in  the  tubercles,  which  stood  in 
no  connection  with  the  open  air,  and  he  concludes  by 
saying  "  that  the  bacilli  of  tuberculosis  are  the  result, 
not  the  cause,  of  the  disease." 

Cases  of  miliary  tuberculosis  are  recorded  by  Prud- 
den  {Med.  Record,  June   i6,  1883,  p.  645)  in  which  "no 


252  DISEASES   OF  THE   HEART  AND    LUNGS. 

bacilli  could  be  detected  by  the  most  exhaustive  search." 
Considerable  evidence  is  available  to  show  that  the  ba- 
cillus is  less  frequently  found  in  tubercle  tissue  than  in 
the  sputa  of  phthisical  persons,  and  that  in  the  former 
it  is  chiefly  found  in  the  walls  and  contents  of  cavities, 
and  in  cheesy  areas,  especially  in  those  that  are  disin- 
tegrating. 


BRONCHITIS.  253 


XIII. 

Bronchitis. 

Bronchitis  may  be  divided  into  three  varieties. 

1st.  Simple,  or  catarrhal,  affecting  only  the  bronchial 
mucous  membranes ;  is  always  acute  and  self  limiting ; 
not  extending  over  two  weeks.  The  rise  of  temperature 
is  but  little,  frequently  none  at  all.  It  is  popularly  con- 
sidered as  "  only  a  cold,  let  it  go  as  it  came." 

2d.  Severe  or  inflammatory  ;  affecting  both  the  mucous 
membrane  and  the  fibrous  sheath.  The  temperature  may 
run  high ;  it  may  be  irregular  in  its  continuafice,  and  be 
of  serious  importance,  frequently  complicated,  or  compli- 
cating pneumonia  and  pleurisy.  It  may  occur  in  the 
course  of  pneumonia.  In  which  case  if  it  be  during  the 
convalescence  it  may  be  surprisingly  and  speedily  fatal. 
It  may  extend  beyond  the  fibrous  sheath  into  the  peri- 
bronchial spaces,  then  it  is  called  peribronchitis.  It  is 
frequently,  if  not  always,  complicated  with  plastic  exuda- 
tion within  the  pleurae ;  the  physical  signs  of  which  are 
mistaken  for  the  disease  itself. 

3d.  When  it  becomes  peribronchial  or  interpleural  in 
its  complications  it  is  called  chronic  bronchitis,  for  the  in- 
flammatory and  plastic  conditions  have  a  tendency  to  con- 
stantly recur  and  the  plastic  pathological  products  are 
more  or  less  permanent. 

Catarrhal  Bronchitis. 

Uncomplicated,  this  disease  affects  only  the  bronchial 
mucous  membrane.  Its  causes  are  sudden  changes  of 
temperature  from  hot  to  cold,  or  from  cold  to  hot,  or  e^^^ 


254  DISEASES   OF   THE   HEART  AND   LUNGS. 

posures  to  wind,  or  dampness  with  insufficient  clothing. 
Or  it  may  occur  from  local  irritation  of  the  mucous  mem- 
brane, as  from  dust  or  other  extraneous  matter,  or  it  may- 
be from  irritating  gases.  Its  site  is  the  mucous  mem- 
brane of  the  tidal  air  passages.  It  does  not  extend  into 
the  true  respiratory  system,  which  is  constantly  occupied 
by  the  residual  air.  Its  limitation  is  anatomical.  It  only 
affects  the  mucous  membrane  supplied  by  the  superficial 
bronchial  arteries. 

It  has  but  little,  if  any  rise  of  temperature,  and  is  un- 
accompanied by  constitutional  symptoms.  It  does  not 
affect  the  appetite  nor  digestion. 

It  is  sometimes  epidemic  in  its  character,  affecting 
mostly  the  mucous  membrane  of  the  air  passages  of  the 
nose,  pharynx  and  larynx.  It  is  called  influenza  or 
grippe,  in  which  case  it  differs  from  catarrh  from  ordinary 
causes.  Catarrh  is  only  the  more  prominent  symptom 
of  an  epidemic  disease  affecting  the  organic  life  of  the 
body. 

Physical  Signs. 

There  are  two  stages  of  simple  catarrhal  bronchitis. 
First  or  dry  stage,  in  which  there  is  no  secretion. 

The  broncho-respiratory  murmur  is  harsh  in  character 
and  somewhat  raised  in  pitch.  It  can  be  heard  every- 
where over  the  chest,  but  with  greatest  distinctness  in  the 
neck  and  in  the  upper  part  of  the  chest. 

There  are  no  rales,  that  is,  there  are  no  interrupted 
noises  like  tearing  of  cloth  or  paper.  There  are  some- 
times sonorous  and  sibilant  rhonchi,  continuous  sounds, 
but  these  are  adventitious  and  are  confined  to  the  second 
stage. 

The  broncho-respiratory  murmur  of  the  first  or  dry 
stage,  is  a  dry  murmur  whenever  it  is  heard.     It  is  loud. 


BRONCHITIS.  255 

harsh  and  near  the  ear  in  the  neck  and  clavicular  region. 
It  is  consonated  in  'the  true  respiratory  system.  The 
sound  vibrations  formed  by  the  air-and-tube  friction,  above 
static  air,  pass  downwards  through  the  columns  of  static 
air  in  the  convective  tubes  and  are  delivered  through  the 
air-sacs  into  the  chest  wall  as  in  a  speaking  tube.  It  alters 
and  obscures  the  normal  broncho-respiratory  murmur,  for 
it  is  harsh,  dry  and  raised  in  pitch. 

In  the  second  stage  the  breath  sounds  become  moister 
in  character.  When  mucous  collects  in  the  upper  pas- 
sages in  sufficient  quantity  to  be  moved  backwards  and 
forwards  by  the  tidal  air  there  will  be  mucous  rales, — 
always  large,  and  heard  over  different  parts  of  the  chest. 
Having  no  points  of  greatest  intensity  except  there  be 
pleuritic  adhesions  to  convey  them  into  the  chestwall 
with  greater  intensity  and  clearness. 

These  mucous  rales,  also,  are  intermittent,  for  the  ac- 
cumulation moves  backwards  and  forwards  only  a  few 
times  before  it  is  loosened  sufficiently  and  is  expectorated, 
when  the  rales  cease.  But  in  a  short  time  the  mucous 
collects  again,  and  the  rales  reappear.  They  are  always 
distant  from  the  ear  unless  brought  directly  to  it  by  ad- 
hesions. They  are  heard  over  a  large  space,  if  not*  over 
the  whole  chest,  and  are  always  distinguishable  from  simi- 
lar rales  heard  from  interpleural  causes.  Interpleural 
rales  are  heard  only  over  the  site  of  their  formation.  In- 
terbronchial  over  a  large  space,  if  not  over  the  whole 
lung.  Interbronchial  or  true  mucous  rales  are  intermit- 
tent, and  soon  change  or  pass  away.  They  can  scarcely 
be  distinguished  from  mucous  rales  in  the  nasal  air-pas- 
sages, as  both  are  consonated  in  the  true  respiratory  sys- 
tem and  are  heard  over  a  large  space.  But  this  can  be 
done  by  auscultating  the  neck  with  a  stethescope.  If  they 
are  nasal  or  pharyngeal,  or  laryngeal  they  will  be  heard  in 
the  neck,  but  not  if  they  are  interbronchial. 


256  DISEASES   OF  THE   HEART  AND   LUNGS. 


Treatment  of  Simple  Catarrh  or  First  Division 

OF  Bronchitis. 

During  the  dry  or  inflammatory  stage,  the  treatment 
should  be  for  this  purpose :  First  of  abortion  ;  second  of 
hastening  and  promoting  secretion. 

Abortion  to  be  successful  must  be  attempted  very  early. 
In  ordinary  catarrh  it  may  be  affected  with  quinine  and 
Dover's  powder  or  other  preparations  of  opium,  given  after 
a  foot  bath.  The  patient  should  be  placed  in  bed^,  and 
kept  covered,  but  should  not  be  loaded  with  covering. 
The  object  is  gentle  perspiration. 

This  will  be  promoted  by  using  a  snuff  composed  of 
salicine  one  drachm,  chlorate  of  potash  one  scruple,  and 
pulverized  gum  acacia  half  an  ounce.  This  may  be  drawn 
up  into  the  nasal  passages  by  snuffing,  or  be  thrown  up 
by  an  instrument. 

If  taken  early  the  attack  may  be  aborted.  If,  how- 
ever, the  opportunity  of  abortion  is  neglected,  the  next 
best  thing  to  do  is  to  hurry  the  natural  method  of  cure 
by  promoting  free  secretion.  In  addition  to  the  abortive 
methods  warm  vapor  may  be  inhaled,  and  attention  should 
be  paid  to  the  digestive  organs.  Judicious  stimulation 
may  also  assist. 

A  mixture  of  chloride  of  ammonium  three  drachms, 
chlorate  of  potash  one  or  two  drachms,  cinnamon  water 
six  ounces,  syr.  senega  and  sweet  spts  of  nitre,  each 
one  ounce,  with  extract  of  licorice  to  disguise  taste,  may 
be  of  great  benefit,  when  the  throat  is  severely  attacked. 
This  may  be  given,  tablespoonful  to  an  adult,  every  half 
hour  or  every  two  hours,  according  to  the  results  obtain- 
able. Influenza  or  grippe,  may  be  broken  up,  if  taken  very 
early,  by  the  following  prescription  :  Half  an  ounce  of 
choride  of  ammonium,  half  an  ounce  of  nitrate  of  pot- 


BRONCHITIS.  257 

ash,  half  an  ounce  of  senega  root,  and  one  ounce  of  lico- 
rice root ;  one  pint  of  boiling  water,  infusion. 

If  the  patient  toasts  his  feet  before  a  brisk  fire,  or 
places  them  in  a  hotfoot  bath,  and  takes  of  this  infusion 
one  tablespoonful  every  half  hour  during  an  afternoon 
and  evening,  and  then  retires  to  a  comfortable  bed,  he 
may  arise  the  next  morning  entirely  free  from  the 
attack. 

The  early  and  efficient  treatment  of  acute  bronchial 
catarrh  is  but  prudent  forethought.  It  is  true  that  an 
attack  may  run  an  even  and  uncomplicated  course  with- 
out medication,  ending  in  perfect  recovery,  but  there  is 
always  danger  that  the  inflammation  may  extend  to  the 
fibrous  sheath,  which  may  be  the  beginning  of  serious 
complications,  ending  in  fibrous  phthisis. 

Severe  or  inflammatory  bronchitis  is  characterized  by 
higher  temperature,  severer  constitutional  symptoms,  and 
graver  complications  than  the  conditions  of  simple 
catarrh.  The  inflammation  extends  into  the.  fibrous 
sheath,  and  frequently  beyond  it  into  the  connective  tis- 
sue of  the  peribronchic  spaces.  Peribronchitis  with  in- 
flammation of  the  fibrous  sheath,  has  no  regular  course, 
but  may  continue  for  months  or  years,  and  then  it  is 
called  chronic  bronchitis.  It  does  not  extend  through 
the  whole  of  a  bronchus,  but  is  confined  to  points  of 
limited  extent.  It  results  in  stricture  and  correspond- 
ing dilatation  of  the  bronchus,  and  is  always  compli- 
cated more  or  less  with  interpleural  pathological  re- 
sults, adhesions,  and  thickened  pleura.  In  post-mortem 
examinations  the  evidence  of  simple  catarrhal  bronchitis 
may  entirely  disappear  or  be  so  faint  as  to  escape  detec- 
tion. But  inflammation  of  the  sheath  leaves  the  mucous 
surface  deeply  stained  with  blood  extravasation  extend- 
ing down  into,  the  sheath.  This  complication  rh ay  take 
place  during  convalescence  in  pneumonia.    Occurring  then 


^58  DISEASES   OF  THE   HEART  AND   LUNGS. 

it  is  generally  speedily  fatal,  and  its  existence  is  not  easily 
diagnosticated. 

It  may  be  that  our  knowledge  of  it  may  be  acquired 
only  at  the  autopsy,  for  its  presence  is  not  made  known 
by  physical  signs  during  life.  The  fibrous  sheath  is  sup- 
plied by  the  deep  bronchial  arteries,  being  allied  to,  and 
yet  different  from,  the  mucous  membrane  which  is  sup- 
plied by  the  superficial  bronchial  arteries.  The  deep  and 
the  superficial,  however,  have  the  same  origin,  and  thus 
are  nearly  related.  They  have  another  bond  of  union  in 
the  fact  that  both  contribute  to  the  formation  of  the 
nutrient  artery  of  the  true  respiratory  system.  The 
nutrient  arteries  of  the  lungs  have  no  returning  veins, 
consequently  disease  of  the  true  respiratory  system  or 
plastic  exudation  upon  the  pulmonary  pleura  must  affect 
both  the  mucous  membrane  and  the  bronchseae,  and  also 
the  fibrous  sheath,  producing  peribronchitis  and  chronic 
catarrh.  We  often  hear  the  terms  catarrhal  pneumonia 
and  broncho-pneumonia  used  by  those  who  scarcely  com- 
prehend the  anatomical  conditions  of  their  pathology. 
It  is  not  possible  that  pneumonia  nor  plastic  exudation 
upon  the  pulmonary  pleura  should  take  place  without 
engaging  the  vessels  of  the  bronchgepe,  both  deep  and  super- 
ficial, and  consequently  causing  more  or  less  bronchor- 
rhoea.  And  yet  for  a  time,  perhaps  a  long  time,  there 
may  be  no  mucous  secretion,  no  expectoration,  but  a  dry 
and  ineffectual  cough-  Eventually  there  will  be  secretion 
and  great  relief  thereby. 

The  interpleural  and  peribronchial  complications  are 
so  constant  and  immediate  that  we  must  take  note  of 
them  at  once,  even  while  considering  the  primary  lesion. 
They  are  so  intimately  connected  that  signs  of  plastic 
exudation  within  the  pleura  and  in  the  peribronchial 
spaces  become  the  physical  evidences  of  commencing 
fibroid  phthisis.    Should  an  attack  of  simple  catarrh 


BRONCHITIS.  259 

be  extended  in  time,  with  higher  temperature  and  greater 
constitutional  disturbance  than  usual,  we  must  search  for 
physical  signs.  These  consist  in  greater  intensity  of  the 
exaggerated  breath-sounds  in  inspiration,  and  a  distant 
sound  like  a  suppressed  moan  in  expiration.  When  these 
signs  are  heard  we  need  not  wait  for  further  physical  evi- 
dence, but  proceed  at  once  to  more  vigorous  treatment. 

Antiplastic  remedies,  mercurial,  or  the  salts  of  potash 
or  ammonia,  should  be  given  at  once,  for  delay  is  danger- 
ous. Exudative  inflammation  having  taken  place,  its  re- 
sults may  be  difficult  to  remove. 

They  establish  a  proclivity  to  further  attacks  of  like 
character. 

When  treated  vigorously  primarily  no  secondary  results 
.ensue.     It  does  not  become  chronic  bronchitis. 

But  should  the  proper  treatment  at  the  proper  time  be 
neglected,  there  will  occur  organized  plastic  exudations 
peribronchial  and  interpleural,  and  what  is  called  chronic 
"bronchitis  will  be  the  result. 

The  proper  name  for  this  pathological  condition  is 
fibroid  phthisis.  It  is  progressive  in  its  character.  It 
extends  into  and  destroys  more  and  more  of  the  true 
respiratory  system,  causing  functional  death.  There  is 
loss  of  weight,  frequent  and  difficult  respiration,  expectora- 
tion of  yellowish,  grayish  bronchial  mucous,  sometimes 
haemoptysis.  When  a  portion  of  the  lung  becomes  con- 
soHdated  it  may  become  tuberculated,  with  cheesy  degen- 
eration and  cavities  or  tubercular  nodules  may  be  formed 
in  the  lung,  which  softening  and  opening  into  a  bronchus 
may  cause  pneumorrhagia  or  fatal  haemoptysis.  Or  they 
may  open  into  the  pleural  cavity,  causing  hydro-pneumo- 
thorax. 

Simple  catarrhal  bronchitis  may  thus  end. 


26o  DISEASES   OF  THE  HEART  AND   LUNGS. 


XIV. 

Chronic  Pleurisy. 

If  we  may  include  under  this  term  all  of  the  patholog- 
ical causes  and  results  of  interpleural  effusions  of  fluids 
and  of  exudations  of  plastic,  fibroid,  albuminoid,  and 
Other  exudative  matter ;  whether  as  the  result  of  inflam- 
mation or  of  simple  atony  of  tissues,  then  the  subject  is 
comprehensive  and  makes  it  necessary  to  glance  hurriedly 
at  the  formative  causes. 

There  may  be  three  divisions  of  this  subject.  The 
acute  inflammatory,  the  sub-acute  inflammatory,  and  the 
passive  or  non-inflammatory. 

Acute  Inflammatory  Pleurisy  comes  suddenly  with  a 
chill  followed  by  violent  pain  and  high  temperature,  and 
may  end  fatally  at  the  onset,  or  favorably  with  effusion 
of  serum  into  the  pleural  cavity. 

Its  formative  history  goes  back  but  a  short  time,  and 
generally  where  fluid  is  effused  and  is  removed  there  fol- 
lows speedy  convalescence. 

But  causes  may  intervene  to  prevent  or  retard  recovery. 
The  fluid  may  become  purulent,  or  a  large  amount  of  al- 
buminoid and  fibroid  exudation  may  have  taken  place 
and  then  we  have  chronic  pleurisy  with  its  complications 
and  disabilities. 

Sub-Acute  Pleurisy. — Plastic  exudation  within  the  pleu- 
ral cavity  is  one  of  the  commonest  pathological  results  of 
what  we  call  a  succession  of  colds  and  bronchial  attacks. 
The  physical  signs  of  sub-crepitant  rales,  generally  mis- 
interpreted as  being  evidence  of  bronchitis,  are  really  in- 
terpleural and  denote  plastic  exudation  and  should  be 
called  plastic  rales. 


CHRONIC  PLEURISY.  261 

Usually  the  fresh  exudation  is  rapidly  re-absorbed,  but 
if  the  patient  is  reduced  in  vitality  it  may  remain  and  be- 
come organized  as  adhesions  or  thickened  pleura. 

Wise  management  and  medication  may  hasten  and  en- 
sure its  re-absorption  when  recent,  and  for  this  reason 
bronchial  attacks  should  receive  careful  attention  ;  for 
while  many  times  they  are  but  temporary  indispositions, 
yet  at  others  assistance  is  necessary,  and  the  longer  it  is 
deferred  the  more  difficult  it  becomes. 

The  Sub-acute  form  of  pleurisy  occupies  a  place  mid- 
way between  the  acute  sthenic  form  and  simple  plastic 
exudation  in  which  there  is  no  rise  of  temperature  nor 
pain  nor  any  of  the  accompaniments  of  inflammation; 
which  is  the  third  division  of  this  subject. 

Plastic  Exudation^  Non-Inflammatory. — The  etiology 
of  plastic  exudation  from  mental  or  nervous  depression 
may  extend  backwards  for  months  or  years,  or  it  may 
have  resulted  from  intense  sorrow  of  shorter  duration. 

Any  cause  which  depresses  the  vital  power  and  lessens 
the  vitality  of  the  blood  may  result  in  plastic  exudation, 
the  lax  condition  of  the  tissues  favoring  the  transudation. 

Worry,  disappointment,  despair,  are  the  emotional 
factors.  Atmospheric  influences,  of  a  depressing  char- 
acter, greatly  add  to  the  mental  causes.  It  is  character- 
istic of  this  disease  that  exudations  occur  periodically, 
which  at  first  are  like  thin  glue,  almost  as  fluid  as  serum. 
But  organization  commences  immediately.  I  have  had 
the  opportunity  to  observe  a  plastic  hypersemia  of  the 
lung  in  progressive  pleuro-pneumonia  in  a  cow.  It  was 
of  only  a  few  hours  continuance,  yet  there  were  already 
signs  of  fluid  plastic  exudation  within  the  pleural  cavity, 
which  could  be  heard  as  muffled  moistened  respiration. 
At  the  same  time  a  slight  tearing  sound  occurred  at  inter- 
vals, as  the  ear  passed  over  the  surface,  like  the  tearing 
of  wet  paper. 


262  DISEASES   OF  THE   HEART  AND   LUNGS. 

The  post-mortem  which  immediately  followed  the  physi- 
cal examination  showed,  as  was  diagnosticated,  a  thin ; 
fluid  exudation  covering  the  pleural  surface.  There  were 
slight  filaments  of  forming  membrane  branching  in  dif- 
ferent directions  from  a  central  point.  They  were  scat- 
tered here  and  there,  and  could  be  lifted  upon  the  point 
of  a  knife.  The  movement  of  the  lung  in  respiration^ 
parted  these  filaments  and  caused  the  slight  tearing  rales:- 

Organized  plastic  matter  becomes  adhesions  when  at-- 
tached  to  both  pulmonary  inter-lobular  surfaces,  or  to  the 
pulmonary  and  costal  pleura,  or  to  the  pericardial  sac.  If 
attached  to  one  surface  only,  it  becomes  t/iukened  pleura. 

All  of  these  forms  of  exudative  pleurisy  have  similar 
interpleural  pathological  products,  and  permanently 
lower  the  vital  power  of  the  individual.  They  lessen  the 
capacity  for  blood-aeration  and  consequently  the  amount 
of  blood  lessens  and  the  patient  loses  weight  and 
strength,  and  ability  to  assimilate  food,  and  in  this  state 
slighter  causes  increase  the  pulmonary  hyperaemia  and 
new  plastic  matter  is  thrown  out  to  increase  and  to  ex- 
tend the  disability.  The  organized  exudation  which  was 
caused  by  mental  depression  primarily,  becomes  itself  a 
presistent  physical  factor  of  vital  depression  and  results 
finally  in  progressive  fibroid  phthisis.  Peribronchitis  at 
the  same  time  is  also  progressive  as  a  part  of  the  same 
pathological  processes. 

The  organized  exudation  continues  to  contract,  obeying- 
the  natural  law,  and  if  it  covers  a  large  surface  of  the 
lung,  it  thereby  shuts  off  the  capillary  circulation  both  of 
the  pulmonary  and  of  the  nutrient  arteries,  which  imme- 
diately subtend  the  pleural  surface  so  covered.  At  the 
same  time  the  inflammatory  products  in  the  fibrous  bron- 
chial tube  and  the  peri-bronchitis  more  directly  obstruct 
the  bronchial  and  pulmonary  nutrient  arteries. 

This  untoward  state  of  things  gives  rise  to  many  inter- 


CHRONIC  PLEURISY.  263 

esting  phenomena  not  fully  understood,  except  by  those 
who  search  for  primary  causes  and  look  beyond  the  im* 
mediately  obvious  for  the  essential  causes  of  disease. 

In  this  way  not  only  does  the  contracting  pseudo- 
membrane  lessen  the  area  for  capillary  distribution  of 
pulmonic  blood  for  aeration,  but  it  also  shuts  off  the  cir- 
culation of  the  nutrient  artery  of  the  true  respiratory 
system. 

The  nutrient  artery  is  derived  from  the  bronchial 
artery  with  additions  from  the  mammary  and  the  inter- 
costal, but  has  this  unique  peculiarity  that  I'c  has  no 
venae  comites  or  returning  veins. 

The  capillaries  of  this  artery  after  performing  their 
office  of  nutrition  in  the  true  respiratory  system,  pass 
their  blood  into  radicles  common  to  themselves,  and  to 
the  capillaries  of  the  pulmonary  artery — the  radicles  of 
the  pulmonary  vein— which  carry  all  the  purified  blood  to 
the  left  heart  for  systemic  circulation. 

All  varieties  of  chronic  pleurisy  have  one  common  effect, 
that  of  interfering  with  the  aeration  and  circulation  of 
the  blood,  and  also  lowering  of  the  vital  capacity  of  the 
patient.  They  differ  in  these  particulars  that,  acute  sthenic 
pleurisy  when  it  becomes  chronic,  generally  affects  but  one 
side,  and  may  give  rise  to  curvature  of  the  spine,  but  is  not 
so  liable  to  end  in  pulmonary  phthisis.  The  depressing 
causes  which  were  mainly  or  wholly  efficient  in  the  sec- 
ond and  third  varieties  in  precipitating  the  primary  at- 
tack have  but  little  to  do  as  causes  in  the  first,  but  con- 
tinue to  act  as  depressing  factors  in  the  second  and  third, 
— more  especially  in  the  third — and  it  is  in  these  two  last 
that  I  am  especially  interested,  for  the  knowledge  of 
them  comes  to  the  physician  as  well  as  to  the  patient  and 
friends  as  a  surprise.  Frequently  in  the  subacute  inflam- 
matory variety  the  bronchial  attack  has  been  forgotten, 
and  the  attention  Is  only  drawn  to  the  rational  and  phy- 


264  DISEASES  OF  THE  HEART  AND   LUNGS. 

sical  signs  of  interpleural  plastic  results  which  are  apt  to 
be  mistaken  for  ^*  tuberculosis,"  especially  if  bronchor- 
rhagia  has  taken  place. 

The  malign  effect  upon  all  concerned  of  such  a  mis- 
take is  to  prevent  the  use  of  effective  means  to  pre- 
vent the  phthisical  result  whilst  it  is  yet  remediable. 
For  the  tendency  of  the  results  of  both  the  second  and 
the  third  varieties,  is  to  end  in  phthisis,  either  fibroid  or 
tuberculated  fibroid.  I  would  make  this  distinction,  that 
fibroid,  which  is  frequently  lingering,  and  more  amenable 
to  rational  treatment  is  yet  often  fatal,  but  never  be- 
comes cavicular,  except  it  first  becomes  tuberculated.  In 
my  experience  and  judgment  uncomplicated  tubercular 
phthisis  is  a  rare  disease,  and  the  few  cases  which  I  have 
seen,  presented  none  of  the  physical  signs  which  are  de- 
pended upon  in  making  a  diagnosis  of  phthisis.  F'or 
without  adhesions  of  the  lung  to  the  chest-wall  there  is 
no  telegraphy  nor  phonographic  relations  established  by 
which  centric  changes  may  be  comprehended. 

The  treatment  of  the  first  variety  should  be  prompt  at 
the  outset,  and  if  possible  abortive.  But  if  effusion  of 
serum  take  place,  the  system  should  be  allowed  to  rest 
for  a  week  or  more  with  palliative  medication  only,  un- 
less there  is  great  suffering  from  dyspnoea.  If  that  is 
the  case  it  will  be  best  to  draw  off  a  portion  of  the  fluid 
at  once.  It  is  better  not  to  interfere,  however,  unless  the 
dyspnoea  be  great,  as  keeping  the  pleurae  apart  for  a 
time  prevents  adhesions,  and  subsequent  disability.  If 
the  fluid  is  not  absorbed  or  lessened  in  a  week  or  ten 
days  it  will  be  best  to  interfere  and  withdraw  it.  Per- 
haps not  all  at  once  but  gradually.  Many  times  after  a 
partial  withdrawal  with  aspirator  or  trochar,  the  re- 
mainder will  be  speedily  absorbed  and  healthful  condi- 
tions will  be  resumed.  When,  unfortunately,  adhe- 
sion and  interpleural  pathological  products  remain  from 


CHRONIC  PLEURISY.  265 

whichever  variety,  nature  may  need  assistance  to  remove 
them.  Fresh  air,  out-door  Hfe,  will  do  much,  and  may 
be  sufficient.  But  if  these  fail,  after  a  short  trial,  vigorous 
anti-plastic  treatment  should  not  too  long  be  delayed. 

The  best  medicinal  treatment  is  the  mercurial,  in  small 
doses  in  combination  or  otherwise,  until  slight  constitu- 
tional effects  are  produced.  Then  changing  to  chloride 
of  ammonium,  or  iodide  of  potash.  Alternation  of  the 
mercurial  and  salt  solvents  should  be  continued  until  the 
lungs  are  free  in  their  movements.  Outside  medication 
should  not  be  omitted.  Spirits  of  turpentine  is  the  best 
for  recent  exudation,  then  iodine,  and  lastly  cantharides. 
Tonics  should  be  given  where  indicated.  The  lungs  should 
be  systematically  expanded  by  filling  them  constantly  with 
air  and  holding  the  breath.  The  food  should  be  nutri- 
tious and  of  easy  digestion.  Milk  is  the  type  of  best 
food.  It  relieves  the  kidneys  too,  which  have  the  great 
labor  of  carrying  out  of  the  system  the  tissue  detritus. 


266  DISEASES  OF  THE  HEART  AND   LUNGS. 


XV. 

Therapeusis  of  Mercury. 

The  physician  needs  powerful  medicines  to  control 
disease  ;  none  the  less  because  he  believes  in  **  vis  medi- 
catrix  naturas."  We  require  of  the  surgeon  that  his 
knives  be  sharp  and  that  he  have  skill  to  use  them — that 
he  should  not  use  them  on  wrong  or  slight  occasions. 
In  the  armamentarium  of  the  physician  there  is  no  other 
agent  having  the  powerfully  sedative  and  at  the  same  time 
the  delicately  alterative  effects  which  belong  to  the  dif- 
ferent preparations  and  doses  of  mercury. 

It  has  been  said  of  the  steam  engine  that  its  adap- 
tativeness  is  universal.  It  can  be  made  to  engrave  the 
delicate  tracery  of  a  seal,  or  to  lift  a  man-of-war  out  of 
the  water.  We  may  say  the  same  of  electricity,  its  power 
is  unlimited,  its  control  and  adaptativeness  to  nice  re- 
sults is  marvellous.  So  also  may  we  say  of  mercury. 
Yet  there  is  no  other  remedy  against  which  there  is  such 
a  violently  unreasoning,  and  unwise  prejudice  as  against 
mercury,  especially  against  the  most  useful  of  all  its 
preparations — the  mild  chloride,  calomel. 

How  absurd  would  be  popular  prejudice  against  the 
steam  engine  or  against  electricity  ?  Are  they  not  pow- 
erful for  destruction  of  human  life  if  misdirected  ?  Yet 
they  are  our  obedient  servants  for  good  under  intelfigent 
direction.     So  is  calomel. 

Calomel  may  be  given  in  drachm  doses,  and  save  life 
when  no  other  remedy  can  do  it,  and  no  harmful  result 
follow.  It  may  be  given  in  one  hundredth  part  of  a 
grain   doses    with   the   nicest   ascertainable   effects.      It 


THERAPEUSIS   OF  MERCURY.  26/ 

Simply  heeds  to  be  wisely  adapted  to  the  necessities  for 
its  exhibition. 

Pleuro-pneumonia  as  it  has  prevailed  for  twelve  or 
fifteen  years  in  New  York  is  controllable  in  some  cases 
only  by  the  sedative  action  of  calomel. 

This  agent  is  the  shears  that  may  clip  the  locks  of  the 
destructive  Samson,  and  render  it  a  mild  disease  amenable 
to  simple  nursing  and  gentle  management. 

Dr.  Graves,  on  large  doses  of  calomel  in  acute  inflam- 
mation, says  {"A  System  of  CHnical  Medicine,"  Dublin, 
1843):  ''The  following  remarks  derived  from  very  ex- 
tensive opportunities  of  observation  apply  not  to  the 
treatment  of  chronic  diseases,  nor  to  that  of  inflamma- 
tions, either  slight  in  degree  or  occupying  parts  not  essen- 
tial to  life,  but  to  those  violent  attacks  of  inflammatory 
action  which  so  often  prove  fatal  in  the  course  of  a  few 
days  or  even  hours  by  destroying  the  texture  and  func- 
tion of  vital  organs. 

"  If  a  person  is  seized,  for  example,  with  very  acute  peri- 
carditis, how  unavailing  will  be  our  best  directed  efforts 
unless  they  be  seconded  by  a  speedy  mercurialization  of 
the  system.  If,  on  the  contrary,  the  practitioner  defers 
the  exhibition  of  calomel  or  insufficiently  tises  it,  then 
will  he  have  occasion  to  regret  the  consequences,  and 
witness  either  the  speedy  death  of  his  patient  or  his  con- 
demnation to  the  sufferings  entailed  on  him  by  adhesions, 
valvular  disease,  and  other  sequelae  of  badly-treated  peri- 
carditis." 

I  well  remember  my  astonishment  when  thirty  years 
ago  the  late  Dr.  G.  P.  Cammann  ordered  a  large  dose  of 
calomel  in  an  attack  of  intercurrent  pneumonia  in  a  case 
of  chronic  phthisis ;  and  my  gratification  at  seeing  the 
disease  successfully  controlled  thereby.  It  was,  perhaps, 
the  most  practical  of  all  the  valuable  lessons  which  I  re- 
ceived from  him. 


:i6S  DISEASES  OF  THE  HEART  AND  LUNGS. 

Dr.  Graves  considered  the  speedy  merGurialization  of 
the  patient  as  necessary.  He  quotes  Dr.  Johnson,  in  his 
classical  work  on  the  Diseases  of  Tropical  Climates,  who 
says  '*  we  ought  to  affect  the  constitution  decidedly  and  as 
speedily  as  possible  by  means  of  calomel  given,  not  in 
small  doses  often  repeated,  but  in  doses  of  a  scruple, 
once  or  even  twice  daily." 

But  in  the  sedative  action  we  do  not  contemplate  mer' 
cttrialization  in  the  sense  of  ptyalism  or  salivation. 
And  if  that  should  occur  it  is  accidental  and  unneces- 
sary, and  is  due  to  the  unfortunate  idiosyncrasy  of  the 
patient. 

The  admirable  sedative  effect  of  calomel  when  needed 
is  best  seen  when  it  is  placed  dry  upon  the  tongue  of  the 
patient ;  then,  like  the  touch  of  the  wand  of  the  magi- 
cian, it  instantly  changes  the  conditions  of  death  to  those 
of  life.  There  is  no  absorption  of  the  medicine,  no  ex- 
hausting purgation,  no  salivation. 

The  temperature  at  once  begins  to  fall,  the  heart  to 
gain  strength,  the  plastic  exudations  upon  vital  organs  to 
be  reabsorbed,  and  the  course  of  life  again  runs  smoothly 
on.  Of  course  it  should  not  be  given  in  any  case  where 
simpler  means  would  answer. 

We  may  say  the  same  of  any  medicine.  But  some 
forms  of  inflammation  of  vital  organs ;  of  the  brain,  of  the 
heart,  of  the  lungs  or  kidneys,  or  some  forms  of  dysentery 
or  fevers,  may  be  speedily  fatal,  if  not  arrested  early  in  the 
attack.  In  that  supreme  moment  there  is  no  choice; 
there  is  but  one  remedy.  If  the  physician  hesitates 
then  or  searches  for  other  remedies  in  obedience  to  pop- 
ular prejudice,  the  favorable  moment  may  pass  and  the 
patient  be  lost.  But  even  the  accident  of  salivation  is 
nothing,  even  when  severe,  in  comparison  with  the  death 
of  the  patient.  Loss  of  teeth,  or  necrosis  of  the  jaw,  or 
cancrum  oris,  are  not  accidents  of  the  use  of  the  sedativ£ 


THERAPEUSIS   OF  MERCURY.  269 

action  of  calomel.  Those  follow  only  the  abuse  of  the 
poisonous  effect  of  calomel,  given  in  repeated  smaller 
doses.  There  was  a  time  when  abuse  of  this  powerful 
remedy  was  not  uncommon.  But  such  is  not  the  case 
now.  The  accident  of  salivation  which  may  occur  when 
one  or  two  large  doses  may  be  necessary  is  not  destruc- 
tive to  tissues,  bones,  or  teeth.  It  is  simply  an  annoying 
inconvenience. 

The  poisonous  effect  of  mercury  is  not  its  sedative  ef- 
fect. Any  one  who  has  seen  twenty,  thirty,  or  even  sixty 
grains  of  calomel  placed  on  the  tongue,  at  the  right  time, 
in  a  case  requiring  its  use,  cannot  help  being  gratified  at 
its  beneficence  and  its  power  to  save.  It  has  no  unpleas- 
ant effect,  simply  the  patient  gets  well,«and  the  change 
is  so  quiet  and  so  complete  that  we  feel  doubt  almost 
that  there  ever  had  been  such  danger. 

When  in  the  judgment  of  the  physician  the  time  has 
arrived  for  the  use  of  this  great  remedy,  it  should 
not  be  delayed,  and  the  dose  should  not  be  scrimped. 
The  dose  should  be  ample.  Our  fears  of  public  preju- 
dice make  us  cowardly,  and  we  sometimes  make  the 
mistake  of  giving  too  little,  and  so  may  do  harm.  The 
small  dose  is  dangerous.  It  may  let  the  only  success- 
ful time  pass.  It  may  have  to  be  repeated,  and  the  poi- 
sonous effect  of  mercury  may  take  place.  There  is  no 
danger  in  the  largest  dose  when  it  is  needed. 

It  is  not  absorbed.  It  acts  upon  the  organic  life  of  the 
body,  and  may  strengthen  the  heart's  action,  lower  the 
temperature,  in  a  few  minutes  after  being  placed  upon  the 
tongue. 

Small  doses  given  in  combination  with  opium,  may  be 
very  serviceable.  Calomel  one  half  a  grain,  with  five 
grains  of  Dover's  powder  may  be  of  decided  benefit,  given 
according  to  the  needs  of  the  case  in  progressive  inter- 
pleural fibrination,  or  fibroid  phthisis. 


270  DISEASES   OF  THE   HEART  AND   LUNGS. 

But  the  combination  of  calomel,  tartar  emetic,  and  ni-^ 
trate  of  potash,  mentioned  by  Dr.  Rush  in  1800,  as  the 
fever  powder  of  Pa.  Genl.  Hosp.,  and  which  he  used  in 
treating  successfully  what  he  called  consumption  in  the 
third  stage,  is  admirable  in  fibroid  phthisis  of  any  stage. 

This  combination  may  be  given  with  effect  when  the 
calomel  may  not  exceed  the  one  hundredth  of  a  grain.  In 
the  Polyclinic  Dispensary  we  have  this  combination  ready 
in  the  form  of  tablets  for  convenience. 

The  stronger  tablets  contain  one  fifth  of  a  grain  of  calo- 
mel, one  thirtieth  of  a  grain  of  tartar  emetic,  and  five 
grains  of  nitrate  of  potash.  The  tablet  is  made  up  with 
sugar,  gum,  acacia,  and  licorice. 

The  second  in  strength  is  just  half  the  amount  of  the 
first,  and  the  third  one  fourth.  They  are  allowed  to  dis- 
solve on  the  tongue. 

Bichloride  of  mercury  dissolved  with  muriate  of  am- 
monia, in  Huxham's  tincture  of  bark,  is  also  a  very  service- 
able combination,  and  may  be  given  alternately  with 
iodide  of  potash,  as  in  syphilis.  Fibroid  phthisis  is  fre- 
quently the  result  of  syphilis.  But  whether  a  given  case 
is  so  or  not  the  treatment  is  equally  beneficient. 

Mercurial  inunction  I  have  used  more  frequently  form- 
erly than  at  present.  It  is  not  so  manageable  and  the 
dose  is  not  so  sure  as  when  given  by  the  mouth  or  on  the 
tongue.  But  it  can  be  used,  as  may  also  the  mercurial 
vapor,  in  .some  case^  with  singular  benefit. 


THUJA  OCCIDENTALIS.  2/1 


XVI. 

Thuja  Occidentalis. 

Arbor-vit^,  or  American  white  cedar,  has  for  more 
than  a  hundred  years  been  a  remedy  in  use  for  a  variety 
of  ailments.  It  grows  indigenous  over  the  Canadas  and 
the  United  States.  The  terminal  twigs  and  green  leaves 
may  be  made  into  a  tincture  with  alcohol  (95  per  cent). 

From  this  a  fluid  extract  or  an  elixir  may  be  formed, 
and  used  as  a  medicine,  or  by  external  application.  As 
an  ointment  or  as  tincture  it  has  been  applied  to  indo- 
lent ulcers,  to  warts,  and  to  polypi  with  supposed  bene- 
fit. The  tr.  or  fluid  ext.  applied  to  an  indolently  in- 
flamed pharynx,  with  engorged  tonsils,  on  cotton  or  by 
the  spray,  gives  immediate  relief.  A  method  of  applying 
it  is  to  wind  some  cotton  batting  upon  the  end  of  a  wire 
or  a  probe,  and  charge  it  with  the  tr.  or  fluid  ext.,  then 
requesting  the  patient  to  take  a  full  breath,  and  while 
holding  the  mouth  open,  to  quickly  pass  the  charged 
cotton  over  the  tonsils  and  pharynx.  Upon  withdraw- 
ing the  probe  let  the  patient  shut  his  mouth  and  breathe 
slowly  out  through  the  nose. 

When  there  is  laryngeal  and  nasal  catarrh  combined 
with  engorgement  of  the  pharynx  the  vapor  reaches  dis- 
tant parts  in  the  nasal  passages  in  breathing  out,  as  well 
as  in  the  larynx  in  breathing  in,  and  gives  relief.  The 
engorgement  and  color  of  the  pharynx  and  tonsils  are 
instantly  affected,  as  can  be  seen,  and  the  catarrh  much 
relieved. 

This  remedy  has  been  used  with  supposed  benefit  in 
certain  forms  of  malignant  diseases  characterized  by  en- 


2/2  DISEASES   OF   THE   HEART    AND   LUNGS. 

gorgement  and  hemorrhage.  I  have  seen  cauHflower  ex- 
crescence disappear  in  a  short  time  under  its  influence, 
and  it  seems  to  arrest  the  tendency  to  bleed.  In  the 
early  stage  of  fibroid  phthisis  characterized  by  sudden 
attacks  of  congestion,  haemoptysis,  and  plastic  exuda- 
tions within  the  pleural  cavities,  I  have  seen  these  alarm- 
ing conditions  disappear  in  a  very  short  time  while  giving 
the  patient  twenty  or  thirty  drops  of  the  strong  tr.  or 
the  fluid  ext.  on  sugar  or  in  oil  or  in  cream  every  three 
or  four  hours.  When  the  pulmonary  congestion  is 
complicated  with  suppression  of  the  menses  the  exhi- 
bition of  thuja  may  give  relief  to  both  conditions  speedily 
I  have  known  cases  of  pulmonary  engorgement,  with 
haemoptysis,  with  moist  and  abundant  rales  over  the 
chest  to  be  greatly  relieved  with  two  or  three  days'  use 
of  the  thuja  supplemented  with  terebinthinate  applica- 
tions externally.  The  abundant  moist  rales  disappearing 
so  speedily  would  seem  to  indicate  that  this  remedy  has 
power  over  recent  plastic  exudations  for  their  removal, 
and  in  this  way  arrests  hemorrhage.  Although  not  a 
specific  for  cancer,  or  tubercle,  or  fibroid,  so  far  as  I 
know,  it  may  be  found  to  be  of  great  service  in  control- 
ling these  diseases  by  relieving  the  system  of  hyper- 
aemia  and  hemorrhagic  tendencies. 


INDEX. 


Adhesions,  dangers  of,  24 
Adhesions,  depressing  vital  power, 

27 

Adhesions,  expanding  chest  for,  64 

Adhesions,  firm,  physical  signs  of, 
209 

Adhesions,  pleural,  cases  of,  85  et 
seq. 

Adhesions,  seat  of  conservative, 28 

Anatomy  of  convective  system,  36 

Anatomy  of  respiratory  system,  36 

Aneurism  impairing  acoustic  qual- 
ities of  chest,  140 

Anti-plastic  effect  of  pure  air,  etc., 
63 

Ammonia,  muriate  of,  as  defebrin- 
ator,  23 

Bacilli,  tubercular,  245 

Bayles'  discovery,  243 

Bean  on  respiratory  murmurs,  33 

Breath  sounds,  Laennec's  descrip- 
tion of,  32 

Bristow  on  apex  murmurs,  180 

Bronchitis,  253 

Bronchitis,  capillary,  pathology  of, 

95 
Bronchitis,  catarrhal,  253 
Bronchitis,  catarrhal,    physical 

signs  of,  254 
Bronchitis,  catarrhal,  treatment  of, 

256 
Bronchitis,  inflammatory,  257 
Bronchitis,    inflammatory,      treat- 
ment of,  259 
Bronchitis,  severe,  257 
Bronchitis,  simple,  253 
Broncho-respiratory  murmur,  51 
Bronchorrhagia,  97 
Brbnchorrhagi-a  in  cancer,  103 
Bronchorrhagia  in  cirrhosis,  loi 
Brbnchorrhage  in  emphysema,  loi 
Bronchorrhagia,  treatment  of,  108 
Bronchorrhagia  in  tumors^  103 


Broussais'  classification  of  phthisis, 
194 

Calomel  in  plastic  exudation,  63 

Calomel,  sedative    and    absorbent 
action  of,  69 

Cammann  on  cardiac  murmurs,  163 

Cammann   on  minute  anatorhy  of 
lung,  39  ' 

Cammann     on     respiratory    mur- 
murs, 33 

Cardiac  disease,  complications  of, 
masking  signs,  141 

Cardiac  movements,  course  of,  187 

Cardiac  murmurs,  functional,  142 

Cardiac  murmurs,  142 

Cardiac  murmurs,  132 

Cardiac  murmurs,  variety  in  inten- 
sity of,  189  et  seq. 

Cardiac  sounds,  Halford  on  mech- 
anism of,  175 

Cardiac  sounds,  rhythm  of,  132 

Cardiac    valvular    disease,  danger 
in,  156 

Chest,  acoustic  properties  of,  71 

Chest,  the,  as  an  acoustic  instru- 
ment, 138 

Chloride  of  ammonium,  therapeu- 
tics of,  221 

Cholera,      muriate     of     ammonia 
in,  226 

Clark's    classification    of    phthisis, 
194 

Consolidation    impairing    acoustic 
qualities  of  chest,  140 

Corrigan    on  respiratory  murmur, 

34 

Crepitant  rale,  almost  always  inter- 
pleural, 23 

Crepitant  rale,  analysis  of,  49 

Crepitant  rale,  cause  of,  19,  et  seq. 

Crepitant  rale,  mechanism  of,  49 

Crepitant  rale,  seat  of,  49 

Croup,  muriate  of  ammonia  in,  228 


2/4 


INDEX. 


Croup,  muriate  of  ammonia  in,  229 

Diagnosis  of  adhesions  between 
pericardium  and  lung,  91 

Dickson  on  pleuro-pneumonia,  117 

Diphtheria,  chlorate  of  potash  in, 
231 

Diphtheria,  muriate  of  ammonia 
in,  231 

Diphtheritic  croup,  muriate  of  am- 
monia in,  232 

Diphtheritic   laryngitis;    recovery, 

233 

Effusion,  removal  by  trocar,  29 

Effusion,  when  to  operate  for  evac- 
uation of,  29 

Emphysema  impairing  acoustic 
qualities  of  chest,  140 

Expiratory  murmur,  velocity,  the 
cause  of,  43 

Exudation,   non-inflammatory,  261 

Exudation,  plastic,  261 

Exudation,  plastic,  etiology  of,  261 

Exudation,  removal  of  by  vital 
forces,  62 

Face  ache,  muriate  of  ammonia  in, 
223 

Fibroid  phthisis,  cases  of,2io  et  seq. 

Fibroid  phthisis,  causes  of,  205 

Fibroid  phthisis,  climatic  treatment 
of,  215 

Fibroid  phthisis,  expansion  of 
chest  in,  214 

Fibroid  phthisis,  haemoptysis  favor- 
able in,  66 

Fibroid  phthisis,  treatment  of,  209 

Fibroid  phthisis  with  adherent 
pleura,  203 

Gerhard  on  respiratory    murmur, 

311 

Gmelin  on  muriate  of  ammonia,  240 

Haemoptysis,  97 

Haemoptysis  as  a  result  of  adhe- 

,    sions,  85 

Haemoptysis,  differential  diagnosis, 
106 

Haemoptysis,  prognosis  of,  98 

Haemoptysis,  sources  of,  97 

Halford  on  mechanism  of  cardiac 
sounds,  175 

Hasse  on  pathology  of  pleurisy,  83 

Heart,  disturbed  action  and  func- 
tional murmurs  of,  165 

Heart,  mechanism  of  first  sound 
of,  132,  133 


Heart  sounds,  mechanism  of,  167 
Huxham  on  weather  changes,  117 
Hydro-pneumothorax,  case  of,  73 
Interpleural  mumurs,  Stokes  on,  55 
Interpleural  murmurs,  Walshe  on, 

55 

Interpleural  pathological  processes, 
diagnostic  signs  of,  95 

Interpleural  pathological  processes, 
physical  signs  of,  71 

Interpleural  source  of  rales,  cases 
in  proof  of,  59,  et  seq. 

Koch's  investigations,  247,  et  seq. 

Laennec  on  phthisis,  194 

Laennecon  respiratory  m.urmur,  33 

Lindsay  on  muriate  of  ammonia, 
240 

Lung,  convective  system  of,  20 

Lung,  respiratory  system  of,  20 

Lung,  uncomplicated  tubercular, 
196 

Medicated  vapors,  cause  of  non- 
success  with,  45 

Mercury  and  ammonia  as  escharo- 
tics,  240 

Mercury,  Mialhi  on,  238 

Mercury,  sedative  action  of,  268 

Mercury,  therapeusis  of,  266 

Mialhi  on  mercury,  238 

Muriate  of  ammonia,  Gmelin  on, 
240 

Muriate  of  ammonia,  Lindsay  on, 
240 

Muriate  of  ammonia,  Richardson 
on,  241 

Muriate  of  ammonia,  Walshe  on, 
241 

Murmur,  anaemic,  143 

Murmur  of  adhesions,  144 

Murmur,  aortic  diastolic  regurgi- 
tant, 147 

Murmur,  aortic  systolic  obstruc- 
tive, 146 

Murmur  at  apex,  Bristow  on,  180 

Murmur,  apex  beat,  154 

Murmur,  diastolic,  cause  of,  148 

Murmur,     functional,    in     chorea, 

145 
Murmur,    functional    intermittent, 

142 
Murmur,    mitral    non-regurgitant, 

157 
Murmur,  mitral  regurgitant,  cause 

of,  149 


INDEX. 


275 


sympathetic    functional, 
systolic,  of  rheumatism, 


Murmur,  mitral  regurgitant,  site  of 
greatest  intensity  of,  151 

Murmur,    mitral    regurgitant    sys- 
tolic, 149 

Murmurs,  organic  cardiac,  145 

Murmur,  plethoric,  142 

Murmur  presystolic,  158 

Murmur,    presystolic,    significance 
of,  177 

Murmur, 
142 

Murmur, 

143 
Murmur,  tricuspid  intraventricular, 

i6t 
Murmurs,    cardiac,   Camraann  on, 

163 
Murmurs,  cardiac,  classification  of, 

181 
Niemeyer's  classification  of  phthi- 
sis, 195 
Phthisis,  acute,  199 
Phthisis,  adhesions  a  cause  of,  28 
Phthisis  and  cirrhosis;  differential 

diagnosis,  102 
Phthisis,    Broussais'  classification 

of,  194 
Phthisis,    Clark's  classification  of, 

194 
Phthisis,  fibroid,  not  propagated  by 

germs,  246 
Phthisis,  Laennec  on,  194 
Phthisis,  latent,  196 
Phthisis,  new  classification  of,  193 
Phthisis,  Niemeyer's  classification 

of,  195 
Phthisis,   Sydenham's  division  of, 

193 
Phthisis,  tubercular,    treatment  of, 

200 
Physiology  of  respiration,  43  et  seq 
Plastic     adhesions     as     cause    of 

phthisis,  65 
Pleura,  anatomy  of,  71 
Pleurse  in  health,  71 
Pleurisy,  chronic,  260 
Pleurisy,  chronic,  treatment  of,  264 
Pleurisy,  dry,  54 
Pleurisy,  effusion  in,  conservative, 

65 
Pleurisy,    Hasse  on  pathology  of, 

83 
Pleurisy,  sub-acute,  260 
Pleuritis,  24 


Pleuro-pneumonia,  abortive  treat- 
ment of,  25 

Pleuro-pneumonia,  calomel  in,  122 
et  seq 

Pleuropneumonia,  Dickson  on.  117 

Pleuro-pneumonia,  effect  of  civili- 
zation on,  120 

Pleuro-pneumonia,  endemic,  114 

Pleuro-pneumonia,  frequency  of, 
26 

Pleuro-pneumonia  in  1812,  116 

Pleuro-pneumonia,  new  phase  of, 
116 

Pleuro-pneumonia,  typhoid  type  of, 
121 

Pneumonia,  cause  of  exudation  in, 

17 

Pneumonia,  discussion  of  Dr, 
Clark's  paper  on,  17 

Pneumonia,  non-purulent  exuda- 
tion in,  17 

Pneumonia,  physical  signs  of  first 
stage,  19 

Pneumonia,  physical  signs  of  sec- 
ond stage,  19 

Pneumonia,  physical  signs  of  third 
stage,  19 

Pneumonia,  seat  of  inflammation 
in,  17 

Pneumonia,  signs  and  symptoms 
of  complicated.  20 

Pneumonia,  statistics  of,  in  New 
York,  115 

Pneumorrhagia,   97 

Pneumorrhagia,  103 

Pneumorrhagia,  sudden  death 
from,  105 

Pneumorrhagia,  treatment  of,  106 

Pulmonary  circulation,  mechanism 
of,  98 

Pulse,  intermittent,  as  sign  of  car- 
diac disease,   186 

Pulse,  intermittent,  calomel  in,  187 

Rale,  mucous,  interpleural.  77 

Rales  and  expectoration,  78 

Rales,  mucous,  cause  of,  79 

Rales,  site  of,  56 

Regurgitation,  frequency  of,  155 

Regurgitation,  tricuspid.  161 

Residual    air,    forces   acting  upon, 

41 
Residual  air,  molecular  motion  of, 

46 
Residual  air,  motion  in,  21 


276 


INDEX. 


Respiratory  murmur,    analysis  of, 

Respiratory  murmur,  Bean  o^^  33 
Respiratory     murmur,    Cammann 

ReTp'irSory  murmur,  Corrigan  on, 

Respiratory    murmur,    composite 

character  of,  49  ^o;tir^n 

Respiratory  murmur,  composition 

Re^spi^atory  system,  currents  of  air 
Respiratory  murmur.  Gerhard  on, 
Res1>iratory  murmur,  Laennec  on, 

ResVratory   murmur,    reason   for 

analysis  of,  34  - 

Respiratory  murmur,  Salter  on   35^ 
Respiratory    murmur,     Sanderson 

Respiratory   murmur,    Skoda  on, 

Respiratory  murmur,  true    51 
Respiratory   murmur,    Walterson, 

Res'piratory   murmur,  Walshe  on, 
ResVatory  murmur,  Williamson, 

liXirCSt^ofammo- 
Sate  on' respiratory  murmur,  33" 
Sanderson  on  respiratory  murmur, 
Scarlatina,  muriate  of  ammonia  in, 

Sko'dl  on  respiratory  murmur^^  33 
Stokes   on   interpleural   murmurs, 

55 


Sunstroke,  muriate  of  ammonia  in, 

SydlVam's   division   of   phthisis, 

The^rlpeutics  of  the  chloride  of  am- 

monium,  221 
Thuja  occidentalis,  271 
Tonsils,  ulceration  of,  236 
True  tubercle,  genesis  of.  240 
Tubercle     following       adhesions, 

treatment  of,  203 
Tubercle   following  pleural   adhe- 
sions, 201  t     r,AA 

Tubercle,  inoculation  ot,  244 
Tubercular  crackling,  5° 
Tubercular  phthisis    195 
Tuberculated  fibroid  P^  J/s^s,  215 
Tuberculated  fibroid  phthisis,  signs 

Tuberculated  fibroid  phthisis,  treat- 

ment  of,  219        ^  ^^t;^n  m 

Tuberculosis,  plastic  exudation  in, 

Tumors  impairing  acoustic  qualities 

Typhus?e^ver,  muriate  of  ammonia 

in    221 
Valvular  lesions  without  murmurs, 

Walshe' on^nterpleural  murmurs. 

wllshe   on  muriate   of  ammonia, 

Walshe    on    respiratory  murmur, 

witters  on  respiratory  murrnur,  33 
Waters    on    minute    anatomy    of 

WeTthe^'changes,    Huxham    on, 

White's  red  salts,  239         ^„^^„r 
Williams  on  respiratory  murmur,. 

33 


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